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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 /> VTANK <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# ,� �� Z�� 7- 11-irb 0 <br /> A <br /> G Facility Name � ', L.,o A., 663LeAkL Phone#(;2, <br /> Address v l _ 7 5 ;'-31 <br /> TCross Street <br /> Y Owner/Operator C�fi f ` ) �,��,' (� Phoned <br /> oContractor Name '' Phone <br /> N Contractor Address " �eOV CA Lic#77,4'-I' ` Classb C 6ij Del 41 Q H� <br /> T <br /> n <br /> A Insurer M Dt j kD e Q w �� G� SRA{— /Ll Work Comp#S <br /> T ICC Technician's Name Oltt6 Z — (� �' Expiration Date Aj v 4/ i of of 0 <br /> R ICC Installer's Name (fi g .._ L9` Expiration Date j U �/ 3/ �1 <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 7�ip srliy9 i�(J �.> L o oc)c4L QI S�4- <br /> IA <br /> N <br /> K <br /> P ❑ App ved Approved with conditions Disapproved <br /> L (S)Atta hment With Conditions) <br /> AIV l 1) <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.OWNER OR LICENSED AGENTS 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 PERFORM2E 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 Signatur Titleate <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-b��yys�signature and date below. <br /> NAME � � /"7�K L}/ �' TITLE s`r/_f`� PHONE kA( 3 47'"f <br /> ADDRESS <br /> SIGNATURE f ?.3—�---� DATE <br /> EH230038(rev � 0/09) <br /> 1 <br />