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a <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 ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # K 1& Zoq - ` j y - 56-11P <br />A <br />O <br />Facility Name hlWS I& <br />Phone # Z p ( - 3&-j _ i'Jq 5 <br />Address (D7j�j ViCf ir' Pi. Lodi . CA- 96240 <br />I <br />T <br />Cross Street <br />Y <br />Owner/OperatorLam, p <br />Phone # �40-31P7-1-795 <br />C <br />O <br />Contractor Name El116 IT Lolls f—actriI-S Inc. <br />Phone # M- 4U - &33-7 <br />NContractor <br />Address X635 Vel' Wam fir. is <br />CA Lic # Class <br />Me <br />(o Cv C -Io - <br />A <br />Insurer (p Y- �1SuretinC <br />Work Comp <br />Expiration Date <br />TICC <br />Technician's Name Lance <br />R <br />ICC Installer's Name La r+ce uar v <br />Expiration Date <br />Tank system work area <br />87 91 leak detector, UDC 1/2, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />installed <br />(i.e. piping sump, etc.) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved pproved with conditions ❑ Disapproved <br />L <br />(Se)Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name_ _ __ Date <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 AGENTS 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." �q �, J <br />d � � 512,S110 <br />Applicant's Signature ��..W -10L= --Title----Date -------------- <br />— --- — <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. <br />NAME 1QA—,a& 1;, FAI-raAhw---TITLE-1jeQ t5& LfZL4iVe-) PHONE # 409 -4tol -b 33-7 <br />ADDRESS- D535 W(1IWam _Dr. _StD66tDnj G4 615206 - --- ----- <br />SIGNATURE_Ae—a4 Lt.6L— wy _ DATE_ �2q j I <br />EH230038 (revised 02/20/09). <br />1 <br />