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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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> t(TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT C(t(� <br /> F EPA Site# Project Contact&Telephone# (c p}Ait t 0-c j W Z _ I r <br /> A Facility Name Q V t lL S�'o P 6 Phone# r(0 - 6 s}•Fro 0 <br /> I Address 1030 S-rOC(C-r" C A r2 /S— <br /> L <br /> TCross Street _ (M A-,,•( S7- - <br /> Y Owner/Operator v(11- STO P W1 A-R. 6( C_ Phone# S(o _ 6 S-}- <br /> c Contractor Name Lt/A.L T-o.( Et( c 4 a,- 2 ^cr, -15;/ r_ Phone# yt(, • 312 <br /> T Contractor Address 160 (0-Z5— •S A- r o g r 6 a 1 CA Lic# ( (� 7-3t Class A, <br /> R Insurer S-rA-I-r ryµ Work Comp# t 3 pop 2}0 6 <br /> A <br /> cICC Technician's Certification Number $'EF- A-i-TA�C*ED Expiration Date <br /> T <br /> Q <br /> R ICC Installer's Certification Number 5 EF tb Y T-AC O E-4 Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T p i tZ� oo0 $ �- �ASoLc %L L)av- <br /> N p Z 12 , 000 Cr I — GA-SaL�� lloU(L <br /> K <br /> P ElApproved )�Approved with conditions ❑Disapproved <br /> L (See Aft chment With Conditions) <br /> A -?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 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 LAW4 OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: N CERTIFY <br /> THAT IN THE PERFORMANCE OF IHE WORK FOR WHIC THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." � <br /> Applicants Signature TitleRn- _Date Z- 0 <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 signature and date below. <br /> NAME W L-T-" R 1^LG TITLE 6-1'R A'�I'o h _PHONE# 71,6 •3 4-2 <br /> ADDRESS • 0 ' p X O Z f W C A- s6 Ct <br /> SIGNATURE <br /> EH230038(revise 8/3/07) <br /> 1 <br />