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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 ❑ PIPING REPAIR/RETROFIT *UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone #91,6 9/-b-3890, <br />A <br />G <br />Facility Name dAj6Zr&y CLcja "74> <br />Phone#2,aq) —2082 <br />Address 1 � p'3 V1i a G©cc iha-v� �., v S u- C 2� <br />TCross <br />Street �• Srvq' <br />Y <br />Owner/Operator 1>�,A4tiTk),e <br />Phone,& `/3-2o52 Qfb�16' <br />c <br />Contractor Name S �l'L �• <br />Phone # F%6 870— 3990 <br />N <br />T� <br />Contractor Address C-JU /Yil� a <br />CA Lic # 621 �b�, ClassA- -L'jD -� <br />A <br />Insurer " 12 f ► A14 a I F • Qzc) 2q p <br />Work Comp # V jA-7 7_ <br />T <br />ICC Technician's Name A j i� Ora.S '"[ 3 ,. <br />Expiration Date Z / Z p/ 0 <br />R <br />ICC Installer's Name Pte.— 1ph„as j Z - / <br />Expiration Date <br />Tank system work area <br />(Le. 87 piping sump, 91 leak detector, UDC U2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />8-7 i +f+ <br />S <br />� 1 <br />n_ ii tvLCA <br />a ala ' lA 1eaA <br />A <br />N <br />K <br />P <br />❑ Approved 1--&�Approved with conditions ❑ Disapproved <br />L <br />(S ttachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL W0'RK 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 <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." /�%J <br />&A17' '�/i�— — �✓ <br />Applicant's Signature Title 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. CIAO <br />;^�NAME TITLE r�%� PHONE #8 70 --3&V <br />SIGNATURE (am` <br />EH230038 (revised 02/20/09) <br />1 <br />TE / <br />9201 <br />9 <br />