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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 0 PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A r,,�'� <br />A <br />C <br />Facility Name NTr -r taco 2 <br />Phone # <br />� <br />Address MS N. Ste, :Toaw;.-� �t- <br />TCross <br />Street � S_ <br />Y <br />Owner/Operator Pact S.,'Tei t,ne 4` t d lx� I�Tri Clrni <br />Phone # 2 Iq-'�(c4 -,554 <br />C <br />0 <br />Contractor Name Cotler Q InC. <br />Phone# <br />N <br />T <br />Contractor Address S etna Uj Sir-;) N\bl n, C A <br />CA Lie # <br />� O 3 Class <br />A <br />Insurer'Trauefer5 Prc CAS A,-er. <br />Work Comp # DT.JtL81?21 P41510 <br />cT <br />ICC Technician's Name.e C SJIIilCv► <br />Expiration Date <br />o <br />R <br />ICC Installer's Name h <br />�1 Chow �1�i 'd�tlti <br />p. <br />Expiration Date <br />Tank system work area I <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/Z etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />S 1. n <br />,2, 000 <br />- e <br />1 1`13 <br />A <br />N <br />K <br />PP <br />proved Approved with conditions <br />❑ Disapproved <br />A <br />461(See Attactyrient With Conditions) <br />N <br />L� <br />`� �/ zex f <br />Plan Reviewers Name Date <br />72 <br />! <br />APPLICANT <br />MUST PERFORM ALL WORK IN AiKIRRDA E WITH SAN JOAQUI CO NTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LI ED 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 <br />CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFORMANCE TH OR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." �F <br />Applicant's Signature JAN Title : ,C eck '' ' n4 "'' <br />Date 04 Lot,121011 <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. p t f <br />NAME l fil S f l-ci n A oy, �' TITLE Pf.:, eC k Ma(\aq f PHONE # ��� �� � a7 -NOW-) <br />1353 t-J'AHcDWeff Bl Vd <br />EH230038 (revised 02/20/09) <br />1 <br />C <br />TE Z oho 1 <br />