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ENVIRONMtNTAL 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 /> LITANK RETROFIT LIPIPING REP IT L]uDc REPAiFjRETRcFrr 2�—M2 START/EVR UPGRADE <br /> F EPA Site# Projed Contact&Telephone# msvp Ir, 5(4 gj" 6Dj)3k7-±%o <br /> A <br /> C Facility Name S-Te- Pt46L-,Tr- U-10al4s QL22pXWrVbtj YL44-0 Phone# CW), --Vo-7-4-6c)o <br /> Add <br /> I ress <br /> L 5=CW2oj <br /> T <br /> 1 Cross Street <br /> C%!�g <br /> Y Owner/Operator !Sa�� F -r S1A4/xz-f--,& Phone# Lw!n 3by-4-0op <br /> 0 <br /> C Contractor Name Phone# el <br /> (M ) 3&-1 4000 <br /> BagLt� fro-4 1"E:F5 Es --zige- <br /> N <br /> T Contractor Address 2310 t4"&%:1> Cz-R-e-L _�T- CALIC# 7-7 &L Class 18-021 03'r 0-4 0 <br /> R <br /> A Insurer &Nqwl-LW"j- jol"S r-4p-go wCgictu e4qAp� Work Comp#W ejj oc+T I q7 0 1 <br /> C <br /> T ICC Technician's Certification Number ft1-deto18-uir ExpirationDate Wt/wIX040 <br /> 0 <br /> -R ICC Installers Certification Number Eqo 14 4-zg-vir Expiration Date 0,,j/3jjZ0j j) <br /> Tank ID# Tank Size Chemicals Stored to LIST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P LIApproved LJApproved with conditions UDisapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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.OV44ER OR LICENSED AGENTS SK14ATUFZE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR W41CH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKERS COMPENSATION LAM OF CALIF IA" CONTRACTORS 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 PER SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> ar�. -- <br /> LApplicards Si- T. <br /> BILLING INFOR IM14iKON: <br /> Indicate the respo le 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 aftQ4" TXr- TITLE_CzffAa_jjft6M, PHoNE#6,04N 36-7-4Q,),D <br /> ADDRESS 2-3'745 (*P-"=0 C-X79�. 0 CA CI�S 1-40 <br /> SIGNATURE <br /> EH230038(revised 12/31107) <br />