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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, 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 />KTANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETRnFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # ACWACL <br />U/A'- I o -( 6- 3 3- //S-1 <br />A <br />C <br />Facility'Name0 kL FAn. An 16 &,T- 4+- 3 S— <br />Phone # <br />L <br />Address / S IN , ( (Z A+"r LIL 2 2 A c <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator 0 �( 1= LVA Arlt 14 6ir5 <br />Phone # <br />c <br />Contractor Name � <br />P-KaI-LEerzt-L4r, tc. <br />Phone #O 6- 31- 3- <br />T <br />Contractor Address g o)( 10 L f (,ti . s a -c ro C A 9 S6 a r <br />CA Lic # 6 2; Y Class A, 8, µ a Z <br />A <br />Insurer -r A,7 ---E T7U mk> <br />Work Comp # 413 000 cit 2 )-06 <br />C <br />T <br />ICC Technician's Certification Number y r 4 Z - L) i <br />Expiration Date ( /04- <br />RICC <br />Installer's Certification Number S- Z 9 q Z _ U -� <br />Expiration Date 11- 0 1 - <br />Tank <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />p t <br />IZ.(L <br />- <br />R l <br />y NIL <br />N <br />K <br />o <br />-P <br />pproved ❑Approved with conditions <br />❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />�( <br />' <br />Plan Reviewers Name V" Date <br />APPLICANT <br />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 <br />OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON <br />IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAW OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFORMANCE OF HE WORK FOR WHI H THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS <br />SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." _� <br />/' <br />Applicants Signature Title 1, ©'I T (L <br />Date f -L ( Q G <br />IJILLIN(3 IM-UKMA 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 TITLE PHONE # <br />ADDRESS <br />SIGNATURE <br />EH230038 (revised 8/8/06) <br />1 <br />M <br />