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to r <br />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 />Lit TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Sieve <br />A <br />C <br />�l <br />Facility Name '�, S44Z•17019 <br />((, <br />Phone# <br />I <br />ffll // <br />Address �r�cC/7 f C/ 4L l C_l�-4oll �7l/ '�SZi/ <br />,��%S <br />TCross <br />Street MOCIL. � �-7 <br />Y <br />Owner/Operator ��L 7 q C <br />Phone # ZLj - C13 Z -/.3 6' <br />c <br />O <br />Contractor Name iCL C �n0��{6n <br />Phone#ZS <br />T <br />Contractor Address /•7(oIj L i c # [ly/ C Class <br />A <br />Insurer W C�'(7 �� lb t l <br />Work Comp # <br />C <br />T <br />ICC Technician's Name t -(-,--s- tn( L <br />Expiration Date S b <br />QExpiration <br />R <br />ICC Installer's Name d l�'1 Yl % es, <br />Date <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 />❑ Approved 'Approved with conditions ❑ Disapproved <br />L <br />(S e Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date? <br />APPLICANT MUST PERFORM ALL WOR 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 Land date below. C- -C� q �c <br />NAME �AJ h le e n k)("C4 � ttkz_ PHONE # % Z J —�� Z �/� 0 <br />ADDRESS % -7 uJ� IC M i ncl S'� , �C�� Sa n/V r <br />Cp `30 /a <br />EH230038 (revised 02/20/09) <br />