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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 />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT []PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT 1<COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # W (C6l A," WatT9pi 9!6 • 3 43 —11 s <br />� <br />Facility Name (� l C #� <br />Phone # S 3 m - S` - 0 y0 <br />� <br />Address g 3 0(: FA -F BLvD y1i A)-LTSCA, C A- S-33 6 <br />1 <br />T <br />Cross Streetp cv L L A V E. <br />Y <br />Owner/Operator M Er L B 0 IL Lo C i_ Liw , r - <br />Phone # <br />o <br />Contractor Name A C 64k CZ 4 KC E/C_lz cr(( (• _ <br />Phone # <br />T <br />Contractor Address Tj p t 0'a f W S ,p-� l -o 9 S-6 R <br />CA Lic # l� Z 3 Class g Z <br />RInsurer <br />A <br />Work Com # <br />T A�t-tf _ ,/ titJl) p l 3 N 9 2- 2 0 0 <br />TICC <br />Technician's Certification Number S eAL A-1 T-A-fM-" Expiration Date <br />R <br />ICC Installer's Certification NumberEx p iration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />I <br />�i k <br />S 4- - (AT0(—"LIL <br />V nLf <br />A <br />� <br />oil 0 L c"-I— <br />N <br />K <br />3 <br />L 14- <br />�D l �S X't- <br />t. <br />P <br />❑Approved ❑Approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />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 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 PERFORMANCE OF HE WORK FOR WHICji THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature Title C 6A7T__(Z2 A'C-�2 Date y <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 parry 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 />� A G <br />NAME {/ / 1 l �` V✓ T W TITLE ��1 PHONE #2— <br />ADDRESS C A / S76 C <br />SIGNA <br />EH230038 (revisecY12/31/07) <br />1 <br />