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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 />UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />APPLICATION FOR <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT g PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />Site # Project Contact & Telephone # Ck65. '9 Irc�l t <br />Facility Name &T , T tLL 44� Phone # �D 1 ^t' a <br />FIEPA <br />Address S N. S I,, i•'1 St^ <br />T <br />Y <br />t <br />Cross Street Land <br />Owner/Operator P�Ci �-(� Jrot.�� ti�T rt%i" Cd^ s*rn t Phone # 214-464-5591 <br />Contractor Name �e,� er ao �n Phone �(j(p-a'Si-� <br />C <br />Q <br />T <br />Contractor Address 's S i trd ; SIrC:r I>�,�b1 i n, C A CA Lic # :Z.ZO $4 3 Class G <br />R <br />Insurer T� p^ 0145 er r Work Camp # DT".it,t 13 82-4 P41510 <br />(`d e G C <br />A <br />C <br />T <br />t F <br />ICC Technician's Name H. e c)'5J E1 WO Expiration Date <br />ICC installers Name 6f"I_ °d1% <br />A ct, <br />Expiration Date <br />° <br />R <br />Tank system work area Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />f,e. 87 Piping Vl np. 91 leatc CW -CW, UDC 112, etc) <br />r93 <br />A <br />N <br />K <br />P ved proved With conditions ❑ Disapproved <br />L (See Atta nt With Conditions) <br />N Plan Reviewers Names late - <br />APPLICANT MUST PERFORM ALL WORK IN AC4TMENT <br />SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAW <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTHWNER ORLICENSED 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 WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA" % <br />APPIka is 5!pftStt e <br />[. T#le ;% e5 i t)ata C ' 6(o <br />BILLING tNFt}RtiAATI0N: <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 />q()73 -q —I06C? <br />SS <br />AODRE <br />1323 N tact t SLS: 2iU = Lm CA �i � 54- <br />DATE6z iZOil <br />sIGM&I"URE <br />EH230038 (revised 02/20/09) <br />1 <br />