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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 <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 )CUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# W C71P1Y M 4MWL t. Z.i Es <br /> A <br /> O Facility Name 44 %L,0w0%90 Phone# <br /> I Address �1.�•�� '17�r4C�Y' fla►L.�t/C�. <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> C Contractor Name GPV'1T1,6f1'6 — PLYo^-6%1 C Phone# aIZS. 061 . -1496-11111116 <br /> T Contractor Address 0-7L" '046V4* ► C=T W1�1.4a1� C; CALic# A"-74712P Class •Gla• <br /> Z <br /> A Insurer FF%r VP&0p.T•yI CV%oGv.A*y,W C0 , Work Comp# (p-r Vw761?4jSl <br /> T ICC Technician's Name c ?. KJ AJ GAP- Expiration Date <br /> Q ICC Installer's Name Expiration Date <br /> R '1• �►,aJ E'IZA p� broj I(,/ZD 1 I > <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T l <br /> A <br /> N <br /> K <br /> P ❑ ApprovedApproved with conditions El Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 04 AAA Date (Z.' 2,9- ( D <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 <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 P$lF6\JE4=T N/AA440411106112.Date /Z/=7�1� <br /> \QILLN INFORMATION: <br /> Indicate the rep nsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the pa designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility for the billing by signature and date below. <br /> NAME L4=)C y MGIGEa-17"E TITLE 1111P• M PHONE.#x+01 XrW. WO-I.-74-44 )CIC'C3 <br /> Z L` <br /> ADDRESS 407 X1'16(Z�'d°`• L%T. '.3TV..) 9'>0 1..11.1 1 �-^• 014 IS&8 <br /> SIGNATURE DATE 112--2 7�1 C <br /> EH230038(revised 07/22/10) <br /> 2 <br />