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• 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 <br />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 ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />O <br />Facility Name A :, , <br />Phone # , 1477. ? <br />L <br />Address <br />T <br />Cross Street } j_ Lad <br />Y <br />Owner/Operator 1q / 0 o f O( j� <br />Phone # <br />C <br />o <br />Contractor Name 'e fr�LEv�n Ger �1 L f / �� <br />Phone # <br />T <br />Contractor Address ft) jCj 0 yrs, �• <br />CA Lic # A13 1 � 13 Class A4 i, E L. _ <br />A <br />Insurer c, c/; {e! Ck <br />Work Comp # <br />c <br />T <br />ICC Technician's Name � r ;� �GS �l�v <br />Expiration Date <br />P� <br />R <br />t <br />ICC Installer's Name . VC -C, Pi,-rr &L <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 />3 7 [�e L C A,t <br />A <br />N <br />K <br />P <br />❑ Approved pproved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />100, <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 Signat LTitle 6NI1 / &dA' ^ Date J Iy S "% Z►� <br />V 131LLIN(3 INFUKMA I IUN: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br />tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br />this responsibility for e billin,q signatu a and date below. /' �J <br />NAME /. `✓{ vrQO wA�l �; Gl�� TITLE C C iV /Yid r) Lr PHONE # C� 7 % l l /c <br />0 r,�C;'k 14)_ <br />E <br />EH230038 (revised 07/22/10) <br />2 <br />TE 3— C' 1 U 1 -i_ <br />, HA <br />