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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 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 #,oWj 0, dS % - j A&7� <br />A <br />O <br />/j <br />Facility Name 4�` CL f S4` 270 �; 4 7 <br />Phone q,20q 7,� --/ <br />I <br />Address �4��� E. nava,!✓ N+C 17tj ��� <br />T <br />Cross Street vvk�tn al P6 C�A <br />Y <br />Owner/Operator bl�„k,,; Phone q(1;�,' 2 -CF_p1 <br />Contractor Name Phone#o - _ q j 1 /j 76 — f &R-, 3 <br />T <br />Contractor Address c, _ L -. _tA-— ) AIL CA Lic # P,2i Z i ,(, Clas C iL it <br />Rnsurer <br />A <br />Ir, .�i-t- �-t.dk ct � r - <br />/vt �,� S . C . <br />Work Comp # V 74il) <br />T <br />ICC Technician's Name <br />Expiration Date <br />o <br />R <br />ICC Installer's Name " '� ? `� L'- <br />G—�%l ter, tom- . -7 _ . T - u 1 <br />Expiration Date — <br />` `" <br />Tank system work area Tank Size <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />TIC.! <br />A <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 NamealzA 0 -j T� Date <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 <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." �I <br />e01-44e9,C <br />Applicant's Signature [�' - Title ;t Date <br />I:il � � Il iCll►`1��1iil�iL'iIUL`A <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. Q�- /�} / ` +�� 7 <br />NAME ��= TITLE ( /CdV�/ f PHONE #L9/ �/ ', /t, <br />"2.1:5(c, <br />SIGNATURE L - <br />EH230038 (revised 02/20/09) <br />11 <br />M CA)'(- 70 (A., 7 9 <br />TE - ��i✓� <br />X41 <br />