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0 4b <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 />IN TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />G <br />Facility Name Aicc 2 13 0 <br />Phone # <br />I <br />L <br />Address D /V. I i v 5 f, St ton Cc,. <br />I <br />T <br />Cross Street r► -i ►� r L <br />Y <br />Owner/Operator L SC.Ott L. *G r <br />Phone # S_ 3 0 -(x.21 - 077 O <br />o <br />Contractor Name Getter_ ars lelc_ <br />Phone# CfJ _S_S`/- 7S5_3_ <br />T <br />Contractor Address 31 ct/O I e -i Dr: SV: 1-70 <br />CA Lic # .2 Z 0 % 53 Class A '11'ta,c-hc <br />A <br />Insurer fe- COM e A.S t.' n F_,_)e)d <br />Work Comp # Ooo 3 D1 b?� 2005 <br />T <br />ICC Technician's Namehr,'S Th r t <br />Expiration Date 6-30 - R oio <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />Til . 'i ( SLirnIO <br />un Ow.. <br />un Keo L i l <br />A <br />N <br />K <br />P <br />❑ Approved k7Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WOKK 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 <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 />Applicant's Signature _"' Title C - .'C E 020Qd9r Date 9 1 o 9 <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 Ge-r-tler- �Ilc,n MC. TITLE 6Dn-tPC4C.70r PHONE# 925---�� �- 7s'S'S <br />ADDRESS 6 747 S. errq Cyur7. SU 11c 7 . IAV d 1.r) 0 Cg,. 9'-IS6 e <br />SIGNATLIR����- A�1�� Grown DATEttjta 1 <br />EH230038 (revised 02/20/09) <br />1 <br />