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-------------- <br />ENVIRONMENTAL HEALTH ' DEPARTMENT <br />A° JOAQUIN <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (208) 468-3420 Fax: (20.9) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 1aa DAYS FROM THE APPROVAL DATE. INDICATE PERMrrTYPE BELOW. <br />0 TANK RETROFIT 0 PIPING REPAiRIRETROFI.T 0 UDC REPAIR1RIETROFIT Ci COLD START14VR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # — l <br />a" <br />A <br />Facility Plaine � tl y CS : ;� •� f, f Phone #S' f -tom% <br />Address J '`S"s �..°,'� j cse>1� c5 r',7 f�=i <br />Cross Street <br />Y <br />OwnerlQperator-, G. y fi7 �^^nr �tc;i� .. <br />Phone # <br />Phone # <br />C <br />Nanie <br />Contractor c•- C,rt, ir.�" `r ;rte tr , <br />N <br />Contractor Address CA Lic # 300,3 °� j'� Ciass <br />A <br />Insurer fes,-^ f �3 <br />Work Comp # ryF,� 7,^ 74.? . <br />Y <br />1CC Technician's Name 4011. f je;, Vis". <br />Expiration Date <br />0 <br />R <br />ECC Installer's Name /• <br />/lr.,le 4 ,, U , + <br />Expiration Date <br />Tank system work areaDate <br />Tank.Slze <br />Chemicals StoredCurrent(y <br />UST0.0.87Pi�5u";81leekdeteao,Uo411Zetc) <br />Installed <br />T <br />'; - 71 zz <br />A <br />N <br />K <br />P <br />L{ <br />❑ Approved Approved with conditions ❑ Disapproved <br />hment Ith Conditions) <br />N <br />Pian Reviewers Nanta ; ` L Date <br />APPLICANT MUST PERFORM ALL W IN ACCORDANCE WITH. SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN. <br />JOAQUIN COUNTY, CWMRONMENYAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE'FOLLOWING: "I CER7lFY THAT IN <br />THE PERFORMANCE OF 7HE WORK FbR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON 114 SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA. ONTRACTOWS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: W CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WH , THIS PERMIT I,S ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />AppllcanesSigrtaturo Title, �'` t;�G2 <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 Com- C� tz �! { �e � �- TITLE 1 " = 4 --ill # f e' -71 <br />ZI-7 "I AIll 41 <br />SIGMA <br />EH230038 (revised <br />2 <br />TE <br />F9 <br />