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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 />nT• iv oc ronn r I P1P1Nr: RFeaIR/RFTROFIT ❑UDC REPAIR/RETROFIT 4 <br />F <br />EPA Site # <br />Project Contact & Telephone # Cif X&I WA LI -0 A( 1:1.2 - 1 T V <br />A <br />C <br />Facility Name t A, w, 44L ��ti rL k S <br />Phone # ?Orr - 2 %(S` - C L 6 <br />I <br />L <br />Address E L DOt- lL100 ST S o CK T-01( 9520 6 <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator A � C`L F, E- s Vr :(L- p n,t f � � ( �} t A u � � Phone # s Ip - S3 <br />o <br />Contractor Name A L'r6 til & . AL E(_PL �.� � Phone # � _ <br />IN T <br />Contractor Address 9 .p Z t W. &E to 9�� q ( <br />CA Lic# 6 (42-31- Class A, 6 � 14A Z <br />RInsurer <br />A <br />T q? E Fv 010Work <br />Comp #} t 3 Oc0 g Z a A 6 <br />cICC <br />T <br />Technician's Certification Number <br />Expiration Date <br />QICC <br />R <br />Installer's Certification Number S E-� Q -P-1 A-GE!'G/� <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />0 <br />0- ('. A --S O L <br />L) 96(- <br />T <br />N <br />K <br />P <br />❑Approved Approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A/ <br />hn <br />N <br />Plan Reviewers Name �� Date & <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 />"I <br />WORKER'S COMPENSATION LAW OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: CERTIFY <br />THAT IN THE PERFORMANCE OF E WORK FOR WHI THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature Title <br />oiLurvv 11Mrvr\1v1r% I 1. 11 - <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 />NAML(7 wa-(, . * < TITLE C&�(L A -11f p- —PHONE # <br />F. o- $0 )( (0iT- W- SA<c Ty A C A- 9'S'6ct <br />SIGNA <br />EH230038 (revised <br />1 <br />