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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 />aTANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # 5.4 e.tj e SCt <br />A <br />C <br />Facility Name <br />Phone # <br />I <br />Address Z.S'7 i l r (. �t V--� 2, I L, CCC <br />1 <br />T <br />Cross Street y V-fAo 11,t } <br />Y <br />Owner/Operator Gl <br />Phone # --z-C Ct - �j� - 13 6'7 <br />C <br />Contractor Name f1 { �� C Q, "lY� [0 cc r1&— <br />Phone # (D <br />N <br />NCA <br />T <br />Contractor Address <br />CA1-1C¢ (�.. c,'ti'ii r,C S-} <br />LI(CI� <br />(� ClassC(r (' C)q <br />R <br />A <br />Insurer r �" u C t vl S Lt r ct f1 c <br />Work Com # \ <br />p A `I S "3 CS�i <br />T <br />ICC Technician's Name Yl i P j ynGt Lj <br />Expiration Date 15- -4 1 <br />R <br />ICC Installer's Name Y� <br />I� L � S YV�I�v� <br />Expiration Date %4 a-iR, + ) <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑Approvedproved with conditions ❑Disapproved <br />L <br />Z (See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date /:x -/-z., /.!g <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 />16ILLINU INt-UKIVW 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 />-l- <br />NAME �lk L' I? N t�y1 S k Lj TITLE C_.ic- 0 PHONE # "r 0 <br />ADDRESS 1� �-/6 M 1 "L- J+• Rf a Sxt v`!�11 C/� <br />SIGNATURE F -4,1 -X -V-. <br />EH230038 (revised 02/20/09) <br />1 <br />TE 12- I21 /D ) <br />