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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 IXCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# P1MA-14 A-c j W- q,16-3�3 -1(f z-- <br /> A <br /> C Facility Name (64ji W F-5 4* �p p 3 Phone# W6 - VV33 _CFF4 0 <br /> � Address <br /> TCross Street <br /> Y Owner/Operator Nf T 20 v L C C- Phone# �1( - C�c13 Q p <br /> C Contractor Name A. C T-" E,,F C,1 1(I�To I,,(( Phone# CJS( - 3 �3 <br /> T Contractor Address B p x p Z s uJ, Sa 9 S6q t CA Lic# (o / 2.3 >r Class A , B .1442- <br /> AInsurer STA- -r- FU" Work Comp# <br /> T ICC Technician's Certification Number S E k_ Ar-T-A-C WI.A) Expiration Date <br /> RICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T t Z 0 le— S - 0 C I "c I, Utick <br /> A <br /> N <br /> K L) 3 10 14- <br /> P <br /> LP ❑Approved 6�pproved with conditions ❑Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name �' �a Date)— <br /> APPLICANT <br /> at)-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 /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OFT E WORK FOR WHIC THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." /� <br /> Applicants Signature Title l�0 P", f2)A'4CT 0 rL-- Date -Z- <br /> BILLING <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 <br /> �billing by signature and date below. /7 <br /> NAME `�� W �-(, 6, TITLE rZ A--(� -- PHONE# 9',/6 - 3 202— <br /> ADDRESS 2- Q 7-3 9x to z 9— V)- S C P- 9.dip 2 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />