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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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RFTRnFIT ]PIPING RFPAIR/REfROFIT WUDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />O <br />Facility Name `G ��U��' �n <br />Phone #r3 <br />Address p g r Ck� a I <br />T <br />Cross Street <br />Y <br />Owner/Operator IftmaA_ <br />Phone # <br />C <br />Contractor Name Z � 0 rnct <br />Phone # "111p -391 - 31Sp <br />N <br />Contractor Address I <br />CA Lic # 3SISqClass <br />R <br />A <br />Insurer <br />Work Comp # <br />T <br />T <br />ICC Technician's Certification Number <br />Expiration Date <br />Q <br />R <br />ICC 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 />❑Approved ❑Disapproved <br />P <br />,Wpproved with conditions <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date (IZ-1 Z 4t1 % <br />APPLICANT MUST PERFORM ALL RK 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, 1 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." Ill <br />Applicants Signature LjAk & Tit Date - V <br />I L31LLINU INhUKNIHI IUIV: — <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. <br />NAME <br />ADDRESS <br />SIGNATURE <br />EH230038 (revised 8/3/07) <br />TITLE PHONE #. <br />1 <br />