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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 IL UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact& Telephone # IC N A•Ili t, WAL l 09 <br />� <br />Facility NameU (/(_ (:;I -pp t4 6 <br />Phone # <br />� <br />Address (O 3 0 S. Q L (t/ E AVG S To CZ, r0 A 17 s Z 1 5- <br />1 <br />1 <br />T <br />Cross Street E „ jM A -i t,( S T , <br />Y <br />Owner/Operator Q U I. IG S 1-0 P W A -R .e, !VC"� C_ <br /># S( 0. S 4 <br />C <br />Contractor Name (�(J A �p �,( �� (� ��,� �_e# <br />Lhone <br />9.16 - 3 3.3 <br />T <br />Contractor Address p p Z S (,� , S -p ct s641 <br />CA Lic # 6 (4- Z 3 Y Class >4 RA -2- <br />A <br />Insurer T p,--� Fu µ� <br />Work Comp # 00 '� 4 Z <br />c <br />T <br />ICC Technician's Certification Number S% -E- Xrr "*AA <br />Expiration Date <br />RICC <br />Installer's Certification Number t` t <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />t <br />I z V— <br />S-. A --S O G c a4- <br />U laL' <br />N <br />K <br />P <br />❑Approved Approved with conditions ❑Disapproved <br />L <br />(See Aft ment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date b <br />ZZ <br />APPLICANT MUST PERFORM ALL WORK 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 LA OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF HE WORK FOR WHICH,THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />/� n � L -z-' <br />Applicants Signature Title l� &'` 2 Atl—oR-- Date <br />AA <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 W jsignnattu_re and date below. <br />NAME +v(. k C (A A - 1T (- ► �++'� TITLE � TZ A�%`0 PHONE # <br />ADDRESS -?- O, 3 0 K ( O 2s-- , W, S `e TV, C A 7 g-6c� I <br />SIGNA <br />EH230038 (revised 12/31/07) <br />1 <br />