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• <br />0 <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 />I� TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # ( QI-�wr, 9/6 826 6 8.? e <br />„aj <br />A <br />O <br />Facility Name /,q rCcp 13 O <br />Phone # 70 S 7 2 187 <br />1 <br />L <br />Address %9D6 N. E / orc, S t• -S oC Ktd n Ca <br />I <br />T <br />Cross Street t44 r,Me r Lan e <br />Y <br />Owner/Operator (3 P A rc- <br />Phone # S30 6? l 077c <br />0 <br />Contractor Nameler- i2,n Inc.In <br />Phone #o g1SS's / 7SS'.S' <br />T <br />Contractor Address 3/110 6.14 evw p iOr. Su•` e_ 170 <br />CA Lic # 22 %°% 3 Class A-fto, Ch ft/ <br />A <br />Insurer Sfa r e C&7m,0e_n $ wcPn Fvti d <br />Work Comp # 000305x- ?009 <br />T <br />ICC Technician's Name Chr•'S T1) ore)Tc9 rl <br />Expiration Date fj�30/ 2 p�0 <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 />c// STP SVr),J <br />V^Arm& arm <br />q/ acfi 6-c s <br />VnI(nc�wr+ <br />A <br />N <br />K <br />P <br />❑ Approved >dDkpproved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <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 <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 />// q <br />Applicant's Signature Title JCr✓• Ce ,i►'1anc,3er Date <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 />C7 <br />NAME e+t n/ <br />ler- IILi4n Inc. TITLE Con'tr-a,�fior PHONE# 9.T-- ssJ <br />ADDRESS Lam/ �J 7 •S; C rr 4 Court. Sy - e S I� v 61: n . Ca. 9 YS -6 P <br />SIGNATURE . �_ 2G 1101 h Qrowr, DATE Ph 1 L0 g <br />EH230038 (revised 02/20/09) <br />IN <br />