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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />[ITANK RETROFIT D PIPING REPAIRIRETROFIT O UDC REPAIRIRETROFIT U COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # <br />O <br />-- - -- <br />Facility Name LOT- 'TC A0C:,L• ��`jl ���c� ]-L. (' Phone# [)0-- S(�r�.- (p ill <) <br />� <br />Address (.., I . C ALt< �f, -_...� C)AD <br />1 <br />T <br />Cross Street nj cl <br />Y <br />OWner/Operato r'71 l,0•'( J rf,.--(_ LE r-� i S L. L <br />Phone # <br />o <br />Contractor Name ijE,aj C'ud� Udl („ .. <br />Phone# 91 9-Z3h._7Z, <br />T <br />Contractor AddressQSqS LLjL'AS RAnch CA Lie# L8qoq Class g AL, <br />A <br />Insurer.Mi010 4L INSJWork Comp# I I� <br />TICC <br />Technician's Name <br />_ (it.�, ti0�. j I I (� Ati S Cl Vk �! -` •L. Expiration Date 5 30 20 t <br />D <br />R <br />ICC Installers Name 30 <br />� I rf t�191��Z.. ��i?� t?J � "^-� Expiration Date 2p( ' <br />'J'J <br />Tank system work area Tank Size Chemicals Stol'ed urrentl Date UST <br />0.e. er pipma—P. 91lwk d—. uoc Irz. a�.t ., y Installed <br />T <br />A <br />K <br />El Approved ❑ Approved With conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions)) <br />N <br />Plan Reviewers Name Dale <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 Or TI IE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />ORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CFRTIFY <br />THAT IN THE P - MANCE OF HE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WpRKER'S COMPENSATION LAWS <br />OF CALIFORNIA. 1 <br />Applicant's Signature Title 0810 08/05/2016 <br />I BILLING INFORMATION: v t <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 <br />� by signature and date below. j /'� (� <br />NAME -�Q�'[L�J.� (� �+, % - t TITLE-Aq�n�.I N•�/,� t n JP/���H�O�NyE # 'u y�` "f, Z.'(���-5rT <br />ADDRESS( "5�1 �,fiJ Y� NCL _ ��P)�o'J 11.1 YLC4�U1 `•'vt1.11YIO✓l(li `�4 vl I f �Ci <br />SIGNATURE �Lp��n ( /1J [MLS DATE <br />EH230038 (revlsed 12.11-15) 2 <br />C <br />Iif- <br />'J'J <br />