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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 Fast 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 1130 DAYS FROM TH��E��APPIZOVAL DA'I'C. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT U PIPING REPAIR/RETROFIT l9'ItDC REPAIRIRETROt~IT ❑ COLD START/EVR UPGRADE <br /> F ^EPA Site# --� Project Contact&Telephone <?4e-e-k <br /> Facility Narne 7-r•4 <br /> Address r� /f -1Y <br /> Cross street <br /> Y Owner/Operator e.- �—— Phone <br /> o Contractor NameG J7 Phone 4 <br /> Contractor Address IyOQ .�c� ✓�. S CA Llc 9 FP!.3 V.?0 Class <br /> A Insurer M✓ ...y� P <br /> A �a�Sa�t 5.�� fy .L ia_f. C� • —_ Work Com # Cl � <br /> ICC Technician's Name ��ie r'l'1 .-.. ExpirationwDate/a �d / O <br /> Q <br /> ra ICC Installer's Name ,/�J Expiration Date L�,-�,�" cetyl CJ <br /> Tank system work area Tank Size Chemicals Stored Currently N Date UST <br /> (I.u.a7 jAong Bump,97 leak dntectnr,UDC V2,Wc.) Installed <br /> A <br /> N <br /> K <br /> r� W ❑ Appr ed `- 1 . Approved with conditions Disapproved <br /> L (See Attachment With Conditions) 41 <br /> A 22 <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN A00ORDANCA WITH SAN JOAQUIN LN7Y ORDINANCES,STATC LAWS,AND RULES ANO RCGULATIONs Or SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT,OWNER OR LICENSED AGEN'r'S SIGNATURE CERTIFIES THE FOLLOWING: "I C?IRTIFY THAT IN <br /> 1'HE PERFORMANCE OF THE WORK FOR WHICH'PHIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> 'I'0 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRAgTOR'S HIRING Ok SUeCONTRAC7'ING SIGNATURE 0eKNFIES THE FOLLOWING, "I CERTIFY <br /> 11�AT IN THE 12ERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSON$SUOJECT TO WORKER'S COMPENSATION LAWS <br /> OF CAWFORNIA." <br /> Applleaht's Signature C'Q'i4)R 6 4AC e. �'/G/_ Date;_ ✓ 7 Q <br /> - — - -- <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additiooal t;l•ID staff time expended beyond permit payment coverage per tank, If <br /> the pally 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 (24"ale 67 , d!/ ,..._,. .__ —1'ITLF C a�'+► 4A C e / PHC)NE "L��©� t <br /> ADDRESS ;ZYr'C, �S'i iJ��"�/!Q !`7r/'2 Scrl TanCJX< elly 6 <br /> SIGNATURE �RATF^ <br /> EH230036(revised 02J20/09) <br /> 1 <br /> TT/50 39Vd -nIH >iDIIHD EZSEEGET99 90:TT 600Z/bT/b0 <br />