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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/�R UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # ti qt _( � <br />W'u('tl. t LL{ <br />A <br />G <br />i' <br />Facility Name C y`�111rC �� <br />Phone # g 30- X370 <br />� <br />Address 61 - 7S -8W,& ( -T_vg=c4 C >A Sal <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator v-04 USR <br />Phone# a6g-.�' -0370 <br />C <br />Q <br />Contractor Name _� , <br />v (JcCQ. �sitCD c 1L <br />Phone # <br />T <br />Contractor Address (Q Y �; luJl h)F Su. sc,�, i S'( 62. <br />CA Lic # 4 S -t $ ¢ Class .,8 (0 4 (I O <br />R <br />A <br />Insurer C �� `u�sar� 4 cep cr.L <br />Work Comp # 33I b,c <br />C <br />T <br />ICC Technician's Certification Number 5� $� 1 S �3 '- l5 � <br />Expiration Date � 3 � O <br />, 1 <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />[]Approved Approved with conditions ❑Disapproved <br />L <br />A <br />(Se Attachment With Conditions) <br />N <br />Name v <br />Plan Reviewers 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 />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." �f `, , '- <br />61 Ls , <br />4/�f <br />��I.�..t--ii �C.-Title O <br />Applicants Signature 4. `4 X1111,4 Adele, Date :;iJ `n"' J <br />BILLING INF RMATION: <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 fo11t^ `!'W� <br />r the billing jby� signature and date below. (a <br />NAME VA 0) V"6 • L 0 TITLELCi9. ,(�.(_ 64"PHONE # <br />ADDRESS t 0 G &UUti�l AU7kE 1k e i S(( �t- <br />SIGNATURE 14A r Z i Lf e I <br />EH230038 (revised 12/31/07) <br />tZ <br />