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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ID TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# e, <br /> A qXL 14 <br /> C Facility Name Vspc `NOVO Phone# aC�_ <br /> L Address ;� ,E LInL" (?14 (^ oZ <br /> 1 Cross Street 1.E <br /> T W-U SNCXCt.UA--j1 <br /> Y Owner/Operator Sod C5 Phone# �) S 3 <br /> C Contractor Name SGTViC� _�� <br /> Phone# 463 F <br /> N Contractor Address O V� ALt S 3 6A �L� 4M j f 4 C&It I act N Z <br /> T � CA Lic# Gass <br /> R <br /> A Insurer -��� ��SUv�t�t Ci Work Comp#,3'3((DO,LC 3 (C)o <br /> C ICC Technician's Name I �0 O <br /> T � � ��� Expiration Date �(, CA <br /> QICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (.See Attachment With Conditions) <br /> A <br /> N Plan Reviewers NameDate -�- U <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ��''// <br /> l n <br /> Applicant's Signature a4 - ` 'L(.t.C.1.1.<.iTitle �L:�V � Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the <br /> billingbysignature and date below. <br /> NAME MCLV4t1-11-\(, W-CV�t & pTITLE_(IgA 6ri L & lytl PHONE# 4161-ad - <br /> LbG ad - �^30 <br /> ADDRESS 06 IT)C' LtLA- AU-k S(k-L 46S- 64 T J B <br /> J, <br /> SIGNATURE L-4I - JA/ a c,u i DATE_ <br /> EH230038(revised 02/20/09) ` <br /> 1 <br />