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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 Fast 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 RETROFIT OPIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F EPA Site # Project Contact & Telephone # <br />A <br />G Facility Name Z:yrAf,(L i A j,6 Phone # Zp9 _ 4 5 Z- -z--z-1 <br />3 <br />I Address <br />L G 8 S$ 'IC r i u �- PI�w <br />I Cross Street <br />T <br />Y Owner/Operator Phone # <br />0 Contractor Name L&tob Phone # <br />N Contractor Address <br />T CA Lic # 1 H -3 t (o o Class <br />R Insurer <br />A C / -60?- a -t Work Comp# 34242y -t <br />TICC Technician's Certification NL1- � <br />bLL r... Expiration Date j I- � - L7 g <br />Dumber <br />R ICC Installer's Certification Number Expiration Date <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />Plan Reviewers <br />Tank ID # <br />❑Approved <br />Tank SizeI Chemicals Stored <br />Currently/Previously <br />Approved with conditions <br />(See Attachment With Conditions) <br />Date UST Installed <br />i_�Disapproved <br />Date /Z— 7— a--) <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." <br />V <br />- ?-7-07 <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 billing by signature and date below. <br />NAM <br />SIGNATURE <br />EH230038 (revised 8/3/07) <br />TITLE PHONE # <br />1 <br />