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ENVIRONNIMTAL HEALTH DL�ARTMENT <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 />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑Ilnr. RFPAIP/PFTPQr:1T IS11- - 1r„ <br />F <br />A <br />EPA Site #Qdp2-7o$0 (0 <br />o 1rmI/cvm VrbKHUt <br />Project Contact & Telephone # :�,e r 0\.,j (\e4 ih tv. <br />C <br />tn 11 r <br />Facility Name S► let I I' VD WAY Phone # ZOq-aj)--J,t q <br />Address q31,5 El. SbCthil, CA q SZus <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator �1 "I c \\3000q <br />Phone # 2_06J -q13) _3 (0-19 <br />o <br />Contractor NameWavu_g�� l l/1(LSII V(��' 1 �� , <br />Phone #G <br />T <br />Contractor Address T 0 Z>0'1-\'401> VO) (A qSZ(.f ( CA Lic #�Z�j?J�O Class PrISU U I j <br />1 <br />R <br />A <br />I <br />Insurer Work Comp # 2 j?J•`� G� <br />T <br />O <br />ICC Technician's Certification Number 5-2-59 3'9-1 _u I <br />Expiration Date 7J•�3.�t7 <br />R <br />ICC Installer's Certification Number V1 <br />Expiration Date F=• 3 • 09 <br />Tank ID # <br />Tank Size <br />Chemicals Stored Date UST Installed <br />Currently/Previously <br />T <br />A <br />N <br />K <br />P <br />❑Approved �Ppproved with conditions []Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name��9- <br />Date�� <br />APPLICANT MUST PERFORM ALL WORK N 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 <br />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 LAW F CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMAN OF E ORK FOR W I THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />'2 c // <br />Applicants Signature Title ! ) pato <br />BILLING INFORMATION: <br />Indicate the resp sible 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 />respoili for the billing by signature and date below. <br />NAMEnsibTITLE(A_S PHONE # <br />ADDRESS / - d . An 4 1 46 � / ^,- I . / .-. n t-17 U i — <br />SIGNATURE <br />EH230038 (revis6d 12/31/07) <br />1 <br />