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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 REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />D <br />Facility Name � _ c .Q. c �.� �� —��l 4.ov� C - <br />Phone # ct"Tc�y <br />L <br />Addressc3v <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # 21 �{� `� �c V - I S -S'2-- <br />2C <br />C <br />Contractor Name"-'�� <br />Phone # <br />T <br />Contractor Address \ \2 —��r <br />CA Lic # 5.cib%oy Class a CA <br />A <br />Insurers - <br />Work Comp # <br />T <br />ICC Technician's Named �,, <br />Expiration Date <br />R <br />ICG Installer's NameEx <br />Ip' ration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC V2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(Se Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Aw &Z71 Date 6-2—(6 <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO 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 />Applicant's Signature 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 billing by signature and date below. <br />NAME N, -Al TITLE PHONE #\ �� '$5 ^ l 0 C\ -O <br />ADDRESS kk-2-4bO �'y1aC�.� C-�� dl_. � 2 �0.�nC_\�O �"�O CA, <br />SIGNATURE_- ---ilr-a.�Y DATE S "2_77 \ <br />EH230038 (revised 02/20/09) <br />1 <br />