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No J% — <br />ENVIRONMENTAL EALTH 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 PIPI REPAIR PERMI <br />n rPI <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />ITAHV PFTPnP]T IPIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />APhone <br />O <br />Facility Name C11102, <br /># <br />IAddress <br />L <br />S S ,S-- ram <br />TCross <br />Street S <br />, <br />Y <br />Owner/Operator <br />Phone # <br />o <br />Contractor Name <br />Phone # <br />N <br />T <br />Contractor Address �p�, +j <br />CA Lic # Class j3 <br />R <br />A <br />Insurer W� v Work Comp # ,Z 3 <br />C <br />T <br />ICC Technician's Certification Number Expiration Date 5 12 j J <br />QICC <br />R <br />Installer's Certification Number 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 />(See Attachment With Conditions) <br />// 1, <br />N <br />Plan Reviewers Name Date V� <br />1 4 - — A46:1= <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 />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />WORKER'S COMPEN.SkTION LAWS OF CALIFORNIA." CONTRACTOR'S <br />THAT IN THE PERF RM CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />I TIfIP �\\��/J Date <br />nppucai ua —ynawic <br />I IQ 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 billing by signature and date below. � � T� T <br />NAME ;13JLrN+ TITLE ha.!FF /'�J PHONE # G� %/� <br />ADDRESS _ .1 "1 11 eit&4aAj �-L 11'� — C-4 / G <br />SIG <br />EH230038 (revised 12/3 <br />1 <br />Odo <br />