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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 /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A Waterloo Shell 209-369-2252 <br /> � Facility Name Phone# <br /> 1 Address 4315 E Waterloo Road <br /> L <br /> TCross Street <br /> Y Owner/Operator Bill an Cathy Norby Phone# 209-369-2252 <br /> C Contractor Name a ton Engineering, Inc . Phone# 916-372-1888 <br /> 0 <br /> N Contractor Address3900 Commerce Drive CA Lic# 617238 Class HAZ ' <br /> T <br /> R <br /> A Insurer State Fund Work Comp#713-4927-2008 <br /> T <br /> T ICC Technician's Name Expiration Date <br /> 0 ICC Installer's Name P <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T 87 STP sump 15 K Gasoline - 87 <br /> A <br /> N <br /> K <br /> P ❑ Approved roved with conditions ❑ Disapproved <br /> L See Attachment With Conditions) <br /> A / S <br /> N Plan Reviewers Name Date �y <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 /> Applicant's Signature Title 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 billing by signature and date below. <br /> NAME Dulcinea Webb TITLE Compliance Manager PHONE# 916-373-1166 <br /> P.O. Box 1025, West Sacramento, CA 95691 <br /> ADDRESS � <br /> SIGNATURE DATE � ' 22 '07 <br /> EH230038(revised 02/20/09) <br /> 1 <br />