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ENVIRON Ac TAL HEALTH DEO- ARTMENT <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 TA �.g26 c� raEPA jAaP <br /> RETROFIT OR PIPING REPAIR PERMIT Toms-35'o r^o*3rrae-x0& <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PEPNAIT TYPE BELOW: SYSTy"n P"8XM <br /> TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT t]COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name SNoa .TOP►Cuj*J CGut- Y CoaPa a.P�-T�1 Y�-n Phone# q q-6g-3v?y <br /> L <br /> Address yA-*S4..TdN Avfi $TC)aK-m ..3 CA 95205 <br /> Cross Street <br /> T <br /> Y Owner/Operator ppm rn4 ,ft5 C Q gCT SMVXZE5 MOP""45J2 Phone# 440 -310& <br /> C Contractor Name �,��„£�/ �,�7r- p¢.'�gS ya,aC, Phone# *,pq 36-7-4,800 <br /> 0 <br /> N Contractor Address 237,o MA 645= Cs C4.£�4 LOOT EA CA Lic# «7 7Lt.Sp 2 Class p21 G a, p c <br /> A Insurer $TALI CaMP.5�1S. FLWb. q5�� WorkComp#73d,•npbp5sg-�( <br /> C ICC Technician's Name 5ARdD jauAKE Expiration Date OG/2Sf Z,oti4 <br /> T <br /> RICC Installer's Name Expiration Date <br /> Tanks stem work area Date UST <br /> y Tank Size Chemicals Stored Currently Installed <br /> (i.e.87 piping sump,91 leak detector,UDC 112,etc.) <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) ,( I I <br /> A J✓1Q b Z <br /> N Pian 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. 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT INTHE PER �THEWORKFOR WHICH THIS FOR(::: CEPERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title �' 3r hL <br /> MtAd•JPF �2. Date ��'/ ` 20c2 <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 signat a and date below. <br /> �'QSEPA UA GiE y. <br /> NAME- <br /> ADDRESS <br /> E.�£R.PtyLS _0116TITLE CvVEoi 1LA�_ MIllAr6£2.- PHONE# Cpl 3�a-4�8oa <br /> ADDRESS 237v fw-cc= i'�RCc..E #4 L_oDx7 dA iq 52.4.0 <br /> SIGNATURE DATE ®Eo%d6�L <br /> r <br /> EH230038(revised 08/1/11) <br /> 2 <br />