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w <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 KOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone #01 C14 p," W,4 ( l-" W4 •3 -3 - wr <br />� <br />Facility NameU t 11- Sro Z t <br />Phone # <br />� <br />Address I Ict6 W_ LO uls� AV6. _PJA A-wT"c A S-33 6 <br />T <br />Cross Street _ umom Tzl> <br />Y <br />Owner/Operator I S --QP YKMz. 4 k,,TT <br />hone # <br />p <br />Contractor Name A 1 ��� <br />Phone # Cl 6 . _ l S L— <br />N <br />T <br />Contractor Address' O / ID i r S q �-p S6 q ( <br />CA Lic # 1 Z3 Class ,L� , <br />RInsurer <br />A <br />5-1 A -TL- F u µ-ti Work Comp # <br />C <br />T <br />ICC Technician's Certification Number Expiration Date <br />R <br />ICC Installer's Certification Number Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A I <br />Z !L <br />- o L <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 A �Gf, Date G /3 j0 � <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 TO <br />WORKER'S COMPENSATION LAWS IDF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OFT E WORK FOR WHIW THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature Title C R 4-tiTO Date r/t } Ir <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 <br />for the billing by signature and date below. <br />NAME �( j/ k/'(�1,4 TITLE (44A1 R A -f -T In-- PHONE # 't( IP 3 } 3 ' < (S Z <br />EH230038 (revised 12/31/07) <br />1 <br />1 <br />2- <br />