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03/25/2010 TAU 13: 32 FAX 2094683433 SJC EHD 0003/005 <br /> r <br /> ENVIRONMENTAL HEALTH DEPARTMENT , <br /> SAID 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 /> i-� <br /> TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# CLI FF O - 9 5( - 5 <br /> A Sj 1 C Facility Name (JfL(-A•G---- (,-) SZ-� - rn 4ZJ t-(A Phone# ap _951 — I 5i5 <br /> Address 4L� �t� 2CA �� �� ���. -� C(�, 95a 9 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> o Contractor Name L�� �� � � Phone#aO9_53'7_9 3 9 <br /> T Contractor Address CA Lic# ja Q S Class C(o( O Z f <br /> A Insurer 5(,1 (Z. Z Work Comp# y 3 (733Q 9 <br /> C <br /> T ICC Technician's Name %CF- L L Expiration Date <br /> RICC Installer's Name I TC LL Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak Aeleclor,UDC 1/2,etc.) Installed <br /> T G UST <br /> A LI QOt cD SEA,4 <br /> N <br /> K <br /> t <br /> P J ApprovedApproved with conditions Disapproved <br /> L (SeeAttachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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." LdA <br /> /� -Z6/Applicant's SignaturZ'w%tac-, _Title IT T Dale <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 rrfor the billing by signature and Idaatte below. �] -7 �] <br /> NAME ��� O�e Wt I ICtt�VTLE PHONE#ate /' <br /> �5 S 1 L C� �,S !� 9 S�o7 <br /> ADDRESS <br /> SIGNATURE C—1" DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />