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09/26/2008 FRI 16: 47 FAX 2094683433 SJC SRD ®002/007 <br /> 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 /> UTANK RETROFIT UPIPING REPAIRIRETROFIT UUDC REPAIRIRETROFIT COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> Facility Name Phone# <br /> I <br /> L Address <br /> I Cross Stree <br /> T <br /> Y Owner/Operat Phone# <br /> G Contractor Name Phone# <br /> 0 <br /> N Contra for Addres 2 CA Lic# ' Class <br /> T r Z <br /> RInsurer work Comp# i3 Q i IsA <br /> T ICC Technician's Cerlificabon Number Expiration Date g A00 <br /> �J R ICC Installer's Certification Number k1 Y Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A 10 sua <br /> N <br /> K <br /> P VApprove Approved with conditions isapproved <br /> L ( e tachment 'th Conditions) <br /> N Plan Reviewers Name I Date <br /> 0�1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOU COUNTY ORDINANCES,STATE LAW1 AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVI HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANC THE WORK 0 H THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMP SATION LAWS CALI RNIA." IT <br /> HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PE NCE OF T OR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNI . <br /> Applicants Sig I Ti11eSjk� Dale <br /> BILLING INFORMATION: <br /> Indicate the responsibl y 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 /> respo ib'lity for the bill by signatur and date below. ^^ <br /> NAM TITLEV,I.I- <br /> ADDRESS <br /> SIGNAT <br /> EH230038(revised 1 31 7) <br /> 1 <br />