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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 18D DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT 01 COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone #S�t/t �•3 •3 <br />A <br />C <br />Facility Name .t Phone # fVf •3 � .37A <br />L <br />AddressFrywArS *dChOn CA. S <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator Phone # <br />C <br />Contractor Name 1er•. Phone # <br />T <br />Contractor Address C&ejoS 0 CA Lic # Class <br />A <br />InsurerWork Comp #&r? i P /d <br />T <br />T <br />ICC Technician's Name Ex irat!on Date <br />rn p S/iSMBl/ <br />QICC <br />R <br />Installer's Name Expiration Date <br />Tank system work area <br />(1.*. 87 piping amp. 91 Mak dehmox, UDC 12, atc.) <br />Tank Size <br />Chemicals Stored Currently Date UST <br />y Installed <br />T <br />yesawr <br />.aa. <br />'cS C, VA .mow <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name. i(i Data <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: 9 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 />Of' Data e'f h b /I( <br />ApplianYs signanire rUe S&I&LCt la <br />BILLING INFORMATION: <br />Indicate the responsible party to be biked 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. e��► 7X <br />�•► <br />NAMEL�'e*+111- Ie'Jan 1f)C. TrrLE On'Mac v PHONE# T.W "SS�^7XS <br />ADDRESS 7M0 Gs, I d Lcaa g Or. SV:1 a 17a acl b Qcd0414 . C4 '94170 <br />SIGNATURE '_ DATE i9 [Ib /10 <br />EH230038 (revised 02/20/09) <br />