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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 />I9 TANK RETROFIT L . PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # Sieve S e- ,-{-j Q Z"- 462--424,0 <br />D <br />Facility Name Phone # <br />� <br />p� <br />r3 �3 <br />Address �S� C_CLU1+( e 1U-6 D1 . S' tac_ir_+e C� C gLtgq <br />T <br />Cross Street P i (nG , L 4 h P O cLG{ <br />Y <br />Owner/Operator A\(c 4 cl-r <br />Phone # 2 el 2) 2 - 130"7 <br />C <br />Contractor Name c, 7 <br />i e_+(—u I -P (,4 Wl <br />Phone # 0 (c Q <br />T <br />Contractor Address 1-7c, j f ,/o,nA (✓1 S F-- - P1e D <br />CA Lic # L4 °11 e --j 4 Class C (r, i A40 <br />R <br />A <br />Insurer Ili d (Zn+&tiry TrvSltrL't ti <br />Work Comp # fX I Q <br />T <br />ICC Technician's Name r n !.7 <br />Expiration Date SX/V <br />0 <br />R <br />ICC Installer's Name �� j'1 �- r i r)'1l1 n <br />Expiration Date 11zg / <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved �7Approved with conditions ❑ Disapproved <br />L <br />A <br />e Attachment With Conditions) <br />� <br />N <br />Plan Reviewers Nam Date D <br />APPLICANT MUST PERFORML WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRO ENTAL 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 />t31LLINU INI-UKMA 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 bysignatureand date below. r, L1 <br />NAME k 6&A it ee 1 1 ` e o s k o-1 TITLE L� � � <br />C, PHONE # "i s � J 1 0 10 y <br />ADDRESS t�tp t , CA <br />wo- <br />SIGNATURE "2_tx� <br />EH230038 (revised 02/20/09) <br />01 <br />TE 61Zj Io -I <br />