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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor, 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 90 DAYS <br /> ��77FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELO <br /> L14 <br /> ❑TANK RETROFIT PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# {*rcq p,&t WA t.-r" 916 - 3 })d r z <br /> � <br /> Facility'Name V ((L S T O P � Phone# S 0 - 6 F4 - <br /> I <br /> L -4 Z V/Address -+1 /E S T tit S-r0 C 14-M K . C a 9 a S' o <br /> TCross Street 14 A.v.w.Ew o R - <br /> Y Owner/Operator Q( 0((4 AlL 16 111 _ Phone# $`l 0 - ( s�- r 0 p <br /> oContractor Name Phone# q(6 <br /> T Contractor Address$0,4 107'r-, W. s-t to CA 9rG a( CA Lic# 2 3 F Class �Q � g• a 4}2 <br /> A Insurer S-t A- v MA) Work Comp# <br /> T s <br /> ICC Technician's Number Expiration Date <br /> SEE Q TT J4-C EF�� p <br /> Q ICC Installer's Certification Number S %-a- A-'t-T-A-01+" Expiration Date <br /> R <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T I !c r CC) G 8-4 U N <br /> A <br /> N <br /> K <br /> 3 Q'1 0 0 0 4l <br /> P ❑Approved *pproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date -7 G <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 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 TO <br /> WORKER'S COMPENSATION LA S OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE O THE WORK FOR ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." k�4 <br /> Applicants Signature ;�ikz Tite C Ga--rIZ-A<-TV— Date 0 <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 dates below. <br /> NAME�y L�� I' G L KICff/1�^t�G �in C TITLE 9�•�1 R P � PHONE# `I L Fi• 3��` «T Z <br /> ADDRESS C S Q <br /> SIGNATURE �i1Ac t- A <br /> EH230038(revised 8/8/06) r v� ((564 A-6t, - WA-C T-" <br /> 1 <br />