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10 <br />• <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 />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT 9 COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # (Can ex V6 d'16 M�it <br />A <br />G <br />Facility Name f C C'% -1 j ( <br />Phone # �O rj - S 7 -,2'i97 <br />L <br />Address %1C�L �'. ./ 00r,ct ic? Sf St(�C%f"'�c?fi) Co. 2,5_,))0 <br />I <br />T <br />Cross Street c �, e ,' Lc o E-. <br />Y <br />Owner/Operator B (J l /l r(o <br />Phone # <br />`' <br />o <br />t t N <br />Conracor Name �re tt/fit'_ Gil Irl('.. <br />Phone# ISS -SSI- <br />N <br />T <br />Contractor Address t Q"• S <br />_/`/G'%!. C_c rr, , , ir: 17C"I <br />CA 1.1)7c ClassHC;2=iU <br />Rsu <br />A <br />Insurer r 1 eA-gn(j7C , <br />Work Com # i �"-- <br />p (')CC 3 V 1( (7 f <br />C <br />ICC Technician's Name r r <br />Expiration Date <br />R <br />ICC Installer's Name 1 ~ tt ,JS <br />Expiration Date r. /�s -)c/o <br />Tank system work area <br />1/2, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC etc.) <br />T <br />S% 5r � <br />UnJir)v <br />Oct GC,5 <br />A <br />N <br />&'7 S/c ve- S <br />U.)Iroew:l <br />&'7 Cc. r 6C, S <br />K <br />I 54- P <br />U n Kn © vi .') <br />C Vit_ t <br />P <br />❑Approvedlk� Approved 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 />Applicant's Signature , Title 3 \- • ( Date C �% <br />bILLINU INrUKMA I IUN: <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 E i �C 1� 10 r-) Inc. TITLE LC,-) f FC, (-. _t O i PHONE # ')-2S- '"S `5 1 7S'J� <br />ADDRESS 67j? S�C'PU'c CC) L4 t Jil, f e: J I � r;& 1.l) Co./ ��- <br />SIGNATURE/v adv <br />^� <br />EH230038 (revised 02/20/09) <br />1 <br />ral <br />