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• <br />• <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 <br />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 />e-n4h/eP I-1 e <br />A <br />C <br />Facility Name ('�� �(YJ r C%y b `7,6 <br />Phone # Zoe - el3; a -/3e rl <br />IAddress L <br />QS`7S" Cn«r) .SfZcic-bn <br />CW 9Sze� <br />I <br />T <br />Cross Street JOI i= oct-lh i? <br />Y <br />Owner/Operator A V-141 <br />Phone # _2 <br />C <br />Contractor Name (ler) `�frz / Pe f a, (elf `v2 <br />Phone # Q Cf(Q J _c/p G, O <br />N <br />T <br />Contractor Address / <br />/7(Q Lc ` �o:yt � r1 � .�} P/e�2S/•ty%•�t. // <br />CA Lic # <br />C <br />t/el �I Class C!o f •-Dy/o <br />R <br />A <br />Insurer r / <br />.1 r2S�� �� n c c C•=� ,�, ��, c� ���6� � cL PS f <br />Work Com # t✓P,4 Se cl <br />P � <br />TICC <br />Technician's Name v G e/ f v <br />Expiration Date r / 3 <br />Q <br />R <br />ICC Installer's Name L�r� � Cir/�z- <br />Expiration Date <br />p' <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 <br />❑ Disapproved <br />A,-�- <br />ee At c nt With Conditions) <br />�% <br />N <br />Plan Reviewers Name Date <br />�✓ <br />APPLICANT MUST PERFORM ALL WORACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE <br />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 <br />CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN <br />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 />c;�'��j�. <br />Applicant's <br />Signature %t=�a�ti��l �S Title (� <br />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 <br />�� by signature and date below. <br />NAME �� jjh lee o t� fZ TITLE PHONE # %2 <br />SI <br />EH230038 (revised 08/1/11) <br />2 <br />TE -21/3/107- <br />