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�i <br />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 REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />� <br />Facility Name r <br />"_"���. \netnt. W . <br />Phone # Gt � � '7 LA 1-, 2 3 �1 <br />Address T \ 2 �w 7 . `--O ct. C P-1 "l S Z%%. C0 <br />TCross <br />Street <br />Y <br />Owner/Operator S o.�— �� cL�o z <br />Phone # 2%`�) Kloy - 2 5 32 <br />oContractor <br />Name"-'T-��-� ��� ' 42.3 �c,XN <br />Phone # q <br />�.,�„� <br />T <br />Contractor Address �-Z�o ��, �� r <br />CA Lic # S$�o9 Class /-X. C>L <br />AInsurer <br />�_-_ <br />Work Comp # �� E <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name .� �. <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC U2, etc.) <br />$,000 al <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date j <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, I 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."1 <br />Applicard's Signature ! `1 l�.�in.�._]1M7Iitle • --'1 -.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, -k- O�TITLE - , PHONE * ("- % <br />ADDRESS \-2°b� —C`v C� .-��ydl q-1LainC O C-0 l7 QjA l`A- <br />SIGNATURES 2% k O <br />- - - - -- -- DATE <br />EH230038 (revised 02120/09) <br />