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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 REPAIR/RETROFIT dCOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name ' u <br />Phone # `Z -i: -J CI y L it y IS - <br />L <br />Address "3 3 014 ,t L m +o c - k- •, j Zd <br />T <br />Cross Street 14 <br />Y <br />Owner/Operator <br />Phone # -oqej I1. <br />o <br />Contractor Nameit/ <br />Phone # Lp� ��jIS - sf <br />T <br />Contractor Address 2 <br />CA Lic # 3 p_? -70(oClass <br />RA <br />Insurer G 'Work <br />Comp <br />T <br />ICC Technician's Certification Number ,'j ��(; — V �" Expiration Dates ,,fig 01? <br />QR <br />a 5/"15 l ._L) , Expiration Date <br />ICC Installer's Certification Number51-411,50-151.l 7 U9 <br />Tank ID # Tank Size Chemicals Stored Date UST Installed <br />Currently/Previously <br />T <br />A <br />N <br />K <br />P <br />❑Approved proved with conditions ❑Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name Date Z U <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 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 TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFOF7CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />r <br />Applicants Signature Title (, . i '. CLo' Date 2 © 8 <br />BILLING INFORMATION: I <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 />responsibilit for the billing <br />by <br />signature and <br />�date <br />j�below. %'� 1 �j <br />NAME <br />�Yi i�l i ,7/'^T TITLE l/W YLtf PHONE # <br />SIGNA <br />EH230038 (revised <br />3 30 Y LA/e.,�) .g 0 ei vn n. -e-, (.._t, 4 c /C <br />1 <br />