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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 ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # (1,4 Q Z Sae 2,5 r <br />Project Contact & Telephone # <br />L L4 --c <br />A <br />O <br />Facility Name Ukt 1" -e Z Lj e 5,4�0C lk Grc C4 i'S <br />Phone # 3 2,5- Z�r_ 4 -✓r' 2erU <br />I <br />L <br />Address <br />TCross <br />Street <br />Y <br />Owner/Operator (j 1^ / �,� Z ��S �of✓l G (`C /-S <br />Phone # 3 Z3— ZC 4 -5Z4 C <br />C <br />O <br />Contractor Name 50rv,crs C_ <br />Phone # 9 of - 55"? -7o2_ <br />T <br />Contractor Address �iU�'S }� +3�,�n Bl+ W14or(��2� CA Lic# <br />1j�22 34 Class <br />A <br />Insurer _Ska k-, >F-'j—k <br />Work Comp # 7,3 g Q Z-5 <br />TICC <br />Technician's Name FjZrj U -7- <br />Expiration Date <br />R <br />ICC Installer's Name 5215Z 3cxl) - 1 <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 12, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />/ <br />A <br />N <br />K <br />P <br />❑ Approved 'Approved with conditions <br />❑ Disapproved <br />L <br />(See Atta ment With Conditions) <br />/�/� 13, <br />N <br />Plan Reviewers Name V V Date <br />, `y-,, ZDQq <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 />"I <br />TO WORKER'S <br />COMPEN TION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br />CERTIFIES THE FOLLOWING: CERTIFY <br />THAT <br />IN THE PERFORMA CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />P7S <br />7 <br />Applicant's Signature Title <br />Date <br />6 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. r <br />NAMEA'`T 6')?V tre-ti)&A4 '*t TITLE �f�S ' PHONE# <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />Yn-)SS1cn 9Lv>- 4 t- 12m8 1215 <br />1 <br />;y.,cs) 4-4 <br />Ul <br />TE <br />