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31s' ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />� �N^IGWh �A, I'DTelephone: (203 468g3420 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 />FITANK RFTPnPIT ❑PIPING REPAIR/RETROFIT -V�DC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br />F <br />.—.........._ ... _ <br />EPA Site # <br />o�.., <br />Project Contact & Telephone # /><//Z„t -17c yrQS L916 p� ice— 3b8� <br />A <br />C <br />Facility Name A.&,p - MoSs 6AuC <br />Phone #209 23T'�2��G <br />� <br />Address x}-44 YyloSs��\e P -d. Lamin Ca. 95-33(3-- Y7`f7 <br />TCross <br />Street <br />Y <br />Owner/Operator Nt c1C gckecA t 5- <br />Phone �ZCq) 23,1- a S c. <br />o <br />Contractor Name ff M c (�/,Q h ( pu <br />Phone #(91& tg 7b-38 <br />T <br />Contractor Address 2 1 EVA �� W. Ac, CA Lic# 8� i Z g Class/. C(3 e36 <br />R <br />A <br />Insurer L 1 �/ <br />Work Comp # W A -j% bco4-1 ]"71 <br />TICC <br />Technician's Certification Number S <br />Expiration Dates <br />Q <br />R <br />ICC Installer's Certification Number <br />Expiration Date ._L-- •� <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />EW S77AJ A, <br />Oo o <br />B: -C u U4v(- u 0 �� <br />E G <br />A <br />L400 D <br />P22.E—MkU,vX U0 91 <br />N <br />K <br />600 <br />[]Approved Upproved with conditions ❑Disapproved <br />P <br />L <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers NameN akdA, Date f / t Z/ug <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 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 />A ..nrn-Mc lzi nature Title 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 <br />for <br />the billing/by si nature and date below. / C �r <br />NAME /i77 �ti C" t`%' TITLE [ - j— 1~ _PHONE # 2c� <br />EH230038 (revised 12/31/07) <br />C. <br />1 <br />