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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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT XUDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # kRjC jM ALC WA r. s4 9q •3 41 <br />A <br />Facility Name 61 5O <br />U l lL T P *- 3 9 <br />Phone # <br />� <br />Address Z 2 _ F R tM 0 t T 1 S 7`0 G(Gt-Q►( cy 5- 2 0 S- <br />I <br />Street <br />Y <br />Owner/Operator 6L tJ I IG S -ro P VA 1,S Y_ K/T'S ( _ <br />Phone # S-10 - 6S-4- F� S Q o <br />cContractor <br />0 <br />Name A• (T-" S q C, �lE�2�� r, (_ <br />Phone# q16 <br />N <br />r <br />Contractor Address p X torr Lt), �iS'6kt <br />CA Lic# ! Z j k Class A (3• (yj/}Z <br />, <br />A <br />Insurer FJ <br />Work Comp #4!;•0Op09Z}•p� <br />T <br />ICC Technician's Certification Number S ('FAl A -T -T A -C W" <br />Expiration Date <br />RICC <br />Installer's Certification Number A -1--t A -C it" <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />p t <br />I t !L <br />8-+ t: A -S o t, r OV— <br />u 11t IL. <br />A(ZtL <br />`1t `L <br />t� <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 Date 112, sU rl <br />APPLICANT MUST PERFORM ALL WORK 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 COMPENSATIONS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br />THAT IN THE PERFOR A CE THE WORK FOR V�HICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Amlicants Signature Title C 0 wt r' A4_� n— 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 />NAME '/ V t tr W � L -L ��" A- L 6 A TITLE l QI IP- h- PHONE # W6 -'1 4- <br />EH230038 (revised 8/3/07) <br />1 <br />