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1 6 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 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 EPA Site # Project Contact & Telephone #11 -tip tk E MC,4 �_ 577 row <br />C Facility Name$ (�j . Z(t,, yam 4 VUIp CST Phone # _ $ 3 9-3971 <br />Address a 5-p 1 s: SC qAn t1 C 3 a O <br />TCross Street <br />Y Owner/Operator jj W Liv m Phone#,(go O 0 <br />c Contractor Name DOWL&F, G=)Yr�A&J\4` Phone#apnj- 537_t�39(o <br />0 <br />N <br />T Contractor Address a a S iL„ (Q,Zj A(:�) Ro E CA Lic # 8'9 Class C G t j 0104 <br />A Insurer WAur-S A v— �, Z 3 O3 p t Work Comp # <br />C ICC Technician's Name Ex iration Date <br />T �l A•tJ '�l(11TC1-4 �,LL p <br />0 <br />R ICC Installer's Name Expiration Date <br />g-a�S c^iot r <br />Tank system work area Tank Size Chemicals Stored Currently Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) I Installed <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />CAN*- 5 1A, 00o UN1-. REG, GA s <br />cUt-xoo ur4c. -t--v&m. GAs <br />6 VZ�9-- l_. <br />❑ Approved Approved with conditions ❑ Disapproved <br />( ee Attachment With Conditions) <br />Plan Reviewers Name AL 04� Date Q� <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 FIR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." ---)I k _ I l . n. <br />�w , G= __ !! y <br />Applicant's Signature Rifle �C1Vr- - Date_ - r <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 bilJigg by signature and date below. <br />NAMFJ;C)N `y nDe W hi YTITLE PHONE #4a O r-53.% 75 7 G <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />1 <br />DATE 5— — <br />