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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 ®UDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # /ni cHAI�c (,(/A c 10,41 116 -3 3 3 - w s L <br />A <br />C <br />Facility Name Q U I IC S -r01� <br />Phone # <br />I <br />L <br />Address 1156 (,t f . Lo utse— At/ I- <br />I <br />Cross Street /`(, V tit I o ,4 TLa <br />Y <br />Owner/Operator G v L IL St o 0 {M tem te. rvrs , C _ <br />Phone # S- 10 - (, S } - TS -00 <br />C <br />Contractor Name (A/A,1- T-" F-4 G I, ^t E C 2 P -Gr, , _ <br />Phone # ( 1 S- 2-o <br />NCAContractor <br />T <br />Address (30>< tc z r• (A) . S p�-p C A 9 S-6 `t <br />Lie # 6 r 3 t 3 rr Class �, 3 • N A Z <br />R <br />A <br />Insurer S T A -r -r-- F v r -- <br />Work Comp # <br />c <br />T <br />ICC Technician's Certification Number SEE A -1-T- A -C <br />Expiration Date <br />oICC <br />R <br />Installer's Certification Number " ` <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />O 1 <br />1 Z /L <br />A- S 0 G c .1 LAL — F -- <br />V MC <br />A <br />N <br />K <br />❑Approved LKpproved with conditions ❑Disapproved <br />P <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />l'% / <br />Plan Reviewers Name lMG�,t� Date ( ZI 410 / 0 l' <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 OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR ICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />l /Z. b <br />Applicants Signature Title C 0 nt T'IZ A-yt- 0 2-- Date I i) <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 Y h t C 14 41;,t WA Vri-q TITLE C IL- PHONE # 3 �- 3 � l � s' Z. --- <br />ADDRESS 0' 3 0 X / 0 Z fyl/ • S .A -C'7(-0 I C A g S 6 a I <br />SIGNA <br />EH230038 (revised 8/3/07) <br />1 <br />