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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 190 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />D TANK RETROFIT D PIPING REPAIR/RETROFIT O UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # <br />—� <br />Facility Name L TCLAJn�t� �az_s �-•L (2 <br />1 Phone #....-.-..()()._ 569 (Dalt) <br />L <br />Address ``� <br />I <br />Cross Street ofCl <br />Y <br />Owner/Operator71f2AJe-f,- C,E T.E, _ <br />Phone # <br />o <br />Contractor Name kJEy C'odw C�Up.. •. <br />Phone# 919"Z -S 77-c> <br />T <br />Contractor AddressQSriSLUCAS(Zgnch 2ZI•/ �1UGsrvu CALic# <br />0}3.51 Class BJJAZs <br />R <br />Insurer.�i10041. WN JQA10cA. 100-- <br />Work Comp# / I0 b <br />T <br />ICC Technician's Name(�pQ'j„�jl(.(7 {',pt)igtl G�tO <br />Expiration Date 5 I 30 1 tat <br />R <br />ICC Installers Name Q 114N �OI�h Z- -0i?�l, �j' <br />Expiration Date 16 '30 2O((�-----.. <br />Tank system work area Tank Size Chemicals <br />Q.a. B] gpinB s�aP. 91 leak Wo' UDC 12, elc.1 <br />or Currantly Data UST <br />Installed <br />T <br />A <br />N_ <br />K <br />............. . <br />P <br />❑ Approved ❑ Approved With conditions <br />❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <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 AGENTS SIGNATURE <br />CERTIFIES THE FOLLOWING' "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS 10 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 P MANCE OF HE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO W?RKERS COMPENSATION LAWS <br />OF CALIFORNIA. <br />08/05/2016 <br />ARbcan'sSlgnatum rine <br />Dale <br />lI BILLING INFORMATION: v <br />Indicate the responsible party to be billed for additional END 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. /t /'� /� <br />NAME Vf 1j0LL� - 1/t TITLE -A (2%0� 10'���PPHONN�F.# 0 /1 "'I, Z"Q7j oaI <br />ADDRESSt''? j'�t�rl� I�Udel `� IIIA V�C�Vlt/7 "vtfl(iI()✓I(A� I.i�-JC2 <br />SIGNATURE- DATE 0&/05/201 <br />EH230038 (revised 12-11-15) 2 <br />MMV 119�- <br />