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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 <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name '�(o S' I�C� ,� <br />Phone # <br />� <br />Address 5��LvL,(n4(-q C l ui b g 1' <br />TCross <br />Street <br />Y <br />Owner/Operator f �— (Civ-� <- <br />Phone # �� - r(j� - Is 07 <br />C <br />Contractor Name LC� �� Y'ti'� ' <br />Phone # �1 — t 4 l9 © in ('1 <br />Q <br />Yl�cti�C <br />v�� <br />N <br />T <br />Contractor Address 17it� LO • 6 M 1 V1 +` <br />CA Lic # q [ClClass LLQ ( <br />A <br />Insurer l t'i �-L�t � al to �N 1 �f✓ <br />Work Comp # <br />T <br />ICC Technician's Name -J-� V� n - ((5 0-1G V1 <br />Expiration Date <br />R <br />ICC Installer's Name �ph p'1 `PS i�iC1l�1 <br />Expiration Date ti L4 l I <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />)roved ''approved with conditions ❑ Disapproved <br />L <br />( ee Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date d <br />APPLICANT MUST PERFORM ALL W0110K 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 %Cc�1 �PC�n �S �1�1 `% TITLE PHONE # <br />Ccs q ca,Mk rcj S-+- <br />SIGNATUREx <br />EH230038 (revised 02/20/09) <br />I eaSan+V <br />1 <br />DATE (,- � /D I /d <br />