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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Sheet, 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 <br />EBBELOW: <br />[]TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT �JCOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />O <br />Facility Name W Ila e- Wes` Marin <br />Phone #'20 -4.5^/' /SS/ <br />I <br />Address // fr _l <br />ion 66 <br />TCross <br />Street <br />Y <br />Owner/Operator /ntc, S �nC <br />Phone # 20� - <br />o <br />Contractor Name (bin Porv,G'0 <br />Phone # ?09- -39-9396 <br />T <br />Contractor Address ,Z$ZS /QQr f��oad Xve- cel-e.SCf} CA Lic # q3;Zogq Class 6-61� <br />RInsurer <br />A <br />Work Comp # <br />T <br />ICC Technician's Certification Number . j Z "?6 -U T <br />Expiration Date 7-o-5--20/0 <br />R <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />A <br />T <br />1v <br />A <br />N <br />rr <br />C9� C61 ^v"1 Tom` n-nl <br />K <br />P <br />I—!Approved '5�,Approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name ZA&Z�Date b <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 TO <br />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." Ic <br />Applicants Signature .� Title Ctb irv1a i- Date /0-9 LOLig <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 billing by signature and date below. nA <br />NAME bon / ma'`ey TITLE C�#( &_ Mcr�l�.c,1"� PHONE# 209-139-9396 <br />ADDRESS Zg�S /1Qrl(�UGtGF_. l �; e_e yes G; t <br />SIGNATURE' <br />EH230038 (revised 12/31/07) <br />