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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fag: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />OTANK RETROFIT &PING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT <br />F EPA Site # Project Contact & Telephone # I C 11 A -Wt A,}Z- <br />A <br />D Facility Name ©t I p ,� lrg Phone # <br />1 Address 1 F3- k1 0 IC F A -T T7, L v' _ <br />T <br />Cross Street <br />Y <br />Owner/Operator P4 q i4 A. 0((- <br />C Q <br />Phone # s --)o _ <br />o <br />Contractor Name �- <br />A l-TO�t Firt +�(, E=ia. 2 c.c.(� C _ <br />Phone # cf l 6Z - <br />N <br />T <br />Contractor Address B '1(; io Z C" U) • S AC, -r <br />6 q <br />CA Lic # 6 1} 2 3 Y Class A$, µ A 2 <br />R <br />A <br />Insurer <br />IS T k't'E. F J <br />Work Comp # <br />T <br />ICC Technician's Certification Number <br />S E. E p.-7- T /� C 6F� <br />Expiration Date <br />oICC <br />R <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />t <br />g� 00 O <br />NZ <br />q 1 0 0 0 <br />9 t— 6 <br />K <br />3 11-Z'000 I "1jl"h t I% <br />P 1_IApproved 14(pproved with conditions ❑Disapproved <br />L (See Attachment With Conditions) <br />A / �,J <br />N Plan Reviewers Name VA f\IaA-C( Date �/ tOt 0 % <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 LAW OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORM AN OF HE WORK FOR WHI H THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." r <br />Applicants Signature ' Title C-0 r -k- 2 A -t -n 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 billingbysignature and date below. <br />NAME U% R L I TITLE C G' (Z A-C�" k PHONE # V 6 . 3 } 3 1(T L <br />ADDRESS T, A- B X ! O Z T" W. S A-t'ra C A 41—c1-6 Q( <br />r►uWiE►��Iis&AN <br />EH230038 (revised 818/06) <br />1 <br />S -2-- <br />1 <br />L <br />