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• <br />w <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 REPAIR/RETROFIT A COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # -70, 3 . T <br />A <br />G <br />/- <br />Facility Name �%;✓�,� ( � `'� 2 %j ��-�, <br />Phone # 3 - � <br />��� �„� Z rJ <br />I <br />Address �.� l l fJ. t CI A'�c LIVE,�- <br />1 <br />T <br />Cross Street <br />Y <br />Owner/OperatorPhone <br />TSN tS <br />#Ott, <br />c <br />O <br />Contractor Name '�'�>� v, C d�qJ. SC -W1 ,e C-,VC:X,, <br />Phone ff(j -/(I-)- <br />T <br />Contractor Address K) S <br />CA Lic Class/ f►w' <br />RInsurer <br />A <br />ji t Q " l ,s �� , <br />l..' 1r t/ G% � r t 6i 1' <br />Work Comp #WA16 017711 <br />T <br />ICC Technician's Name j,TZ9f, kN c -4,%l0 �, ; �''� �(/r� i f % <br />Expiration Date _ t) � <br />QICC <br />R <br />Installers Name <br />' t -5257-15u-7- U I <br />Expiration Date S= Y-0 <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved /-Approved with conditions ❑ Disapproved <br />L <br />(See Attachment i Conditions) <br />A <br />N <br />Plan Reviewers Name Dae <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, 1 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 />441-;;�- <br />Applicant's SignaturTitle4*/���:� Date '7 1 I <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. ( %/ l'�7 /f�j <br />NAME t ��{� U 'e�� TITLE �"�'� �C �I� PHONE #1_ 0714 /L3 /``J"r'5n�-� <br />ADDRESS G� �� ��1�{CsG'��C��� At <br />SIGNATURE DATE L1�J <br />EH230038 (revised 02/20/09) <br />,-0 <br />