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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# y V 'Q Q Lf g p ( Project Contact&Telephone <br /> � Facility Name Q P C o t' G O Z O Phone# <br /> Address I l Q Q- <br /> TT <br /> Cross Street V S <br /> Y Owner/Operator P �� L p Phone# S(0/tf 3Z- 234 T <br /> c Contractor Name pO��p �j 1 5 o IM £L (toys; c a� Phone# St o 6l 4 -- 310 A HAL <br /> 0 <br /> N Contractor Address CA Lic# <br /> T 2, 00 1�'►l�io-►M.S S-�. � �-� qO � Class <br /> R Insurer S <br /> A -t-o-t-e- �•�,�d, e x P• d•c t'e 2-- Z53- oq wont comp# X12 <br /> TICC Technician's Certification Number Or��eS�o SZ 52-0 ( q — V T Expiration Date 2------------- cc <br /> 0 <br /> R ICC Installer's Certification Number M oAA--% do tl 52-:52,0 (9 — U / Expiration Date ( — j— d d o <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T p } I S 000 30.S o k;Ae 2 0 0 *-PC wc. <br /> A p ls' C�00 tr 2Jdn '� <br /> N <br /> K IZ 2-60 o <br /> P LIApproved EApproved with conditions UDisapproved <br /> L (See Attachment 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 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." `/ , <br /> Applicants Signature " ' V �---�J Title ` �0 1"ld+�a e Date (o —3 —OS <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 PO'r6-A1 S 1Z, VT1 'E CH• T1JC • TITLE�t c �. yVl(r✓\A 4 i PHONE# S(0 /61.4 — 23 � 0 <br /> ADDRESS 2 d O w ``� o-1-�S Jfi• ✓G n Le 0.-1c�,d C (f A q 4S -� T <br /> SIGNATURE V. <br /> EH230038(revised 12/31/07) <br /> 1 <br />