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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, 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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />[]TANK RETROFIT %PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # M I c H AE I WALT -o.11. - 3 4 i- A <br />Facility Name A T GR G O O 5 jA E L L <br />Phone # Z09 - Q31- 363%( <br />Address 1 S- _ A r E tZ C 0 0 'Z t�- <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator t L. C A, -r N l E- NOM B <br />Phone # Z p y- ?3j- 3 <br />o <br />Contractor Name A 14. E/c 2 c -&r,C - <br />Phone # ?(6-3:B-/1 S' L- <br />T <br />Contractor Address $p.� l o v f Vj . S X4, ro C k q j` It f <br />CA Lic # 6/} Z 3 fr Class A a I,rAL <br />RInsurer <br />A <br />S-� ArtL �Ci NSA Work Comp # <br />T <br />ICC Technician's Certification Number 5 E E A -T- T A -C 0- Expiration Date <br />RICC <br />Installer's Certification Number Se-@- A -r r A -C w" Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />I <br />C A7s i <br />A <br />N <br />K <br />❑Approved Approved with conditions ❑Disapproved <br />P <br />L <br />(See Attachment With Conditions) <br />A <br />1-1 <br />N <br />Plan Reviewers Name lava Iwo Date 0 <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'SCOMPENSATION LAW OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF HE WORK FOR ICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants SignatureTitle 0"-T k-4 h Date T—hq 0 <br />BILLING INFORMA I IUN: <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. <br />NAME W Pr1, Bel ��' = �i l +yt4AL CZ6a-(, TITLE ��� 12 A-tfi� n- PHONE # ?16 -3 <br />ADDRESS z O D o !, i O Z S- C A 24-6 g r <br />SIGNATUREM15'* -- <br />EH230038 (revised 8/8/06) <br />1 <br />1 <br />a- <br />