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:a I �y � moll <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 ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # <br />A <br />C <br />Facility Name <br />Phone # <br />Address / ® N CLu i71V-� <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />C <br />0 <br />Contractor Name 4`A!, —/hZPlas <br />Phone # <br />T <br />Contractor Address 2,519 EVEtf6fZA& <br />CA Lic # 82 / 2 ® C Class ,q eio -G <br />R <br />A <br />Insurer <br />Work Comp # <br />T <br />ICC Technician's Name A 0l�' j1®vgas 2 - j <br />Expiration Date - /`- <br />R <br />ICC Installer's Name A Ilt,, 711 52 3 77 Z - <br />Expiration Date - f -2 f <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 />A (See Attachment With Conditions) <br />A <br />N <br />Date <br />Plan Reviewers Name D <br />APPLICANT MUST PERFORM ALL WO IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTA EALTH 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 />% <br />4-- <br />Applicant's Signature Title C o � Date <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. %7 c Q <br />NAME A Ile-%- N/� M*c�l TITLE `-0A1rX*C7E9- PHONE # 14 o 70- SOM) <br />ADDRESS 2519 <br />SIGNATURE DATE 7- <br />EH230038 (revised 02/20/09) <br />1 <br />/441 - <br />