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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 <br />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 REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />APhone <br />O <br />Facility Named - ,�`�\--� �h r�s.r <br /># q%to,) 18S8 -\oq0 <br />I <br />L <br />Address ` <br />y5 . 1J • Spec , O^ V r. o�1L--k c .•— C. <br />1 <br />T <br />Cross Street E <br />Y <br />Owner/Operato �'\'�\a M w� T <br />Phone # qtr 85'8 -logo <br />C <br />Q <br />Contractor Name--T-,-Phone <br />.�k- �.,r..,, r ,' g ...c.. <br /># (R%4v) 8Soib-j6o40 <br />N <br />Contractor AddressCALic# Sggo98 Class A 3 CMM A£s <br />RIr1SUrer <br />A <br />Work Comp # U$ --7 e-► 03 <br />T <br />ICC Technician's Name C�Ia«� c Expiration Date a 30 11 <br />R <br />ICC Installer's Name s. <br />Expiration Date jp o,-1 <br />L <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 1/2, etc.) <br />T <br />b�ESE� <br />a5, o00 <br />;o.Esc <br />��.N wto13 <br />A <br />N <br />K <br />P <br />❑ Approved Xpproved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />av� <br />Plan Reviewers Name <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDAN WITH SAN JOAQUIN COSkZLj9kDINANCES, 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 <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 L— itle .o ate L <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for the billing by signature and date below. � ,n A <br />NAMEM�e.�nG.�TITLE-�l� e -c -A V \AyN& td_- PHONE # (0- ��b"IOaC� <br />ADDRESS ♦\2.i30—�rc�c�l.tL� ���LL1... �fL�.Il� F-o►�^c-�" o �IDY�o�J-14 C-� asly Z <br />SIGNATURE �D9�` - - DATE <br />EH230038 (revised 07/22/10) <br />2 <br />i, E1A'L <br />