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03/07/2011 10:27 2093651569 TANKNOLOGY PAGE 03/03 <br /> 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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> AC Facility Name rer Phone# 7��-61 - S ! W <br /> 1 -3-71,16 <br /> Address <br /> '3_too xt Yicc�L:4ur.k' �� '1•rtc�c�.L__ <br /> L <br /> ? Cross Street <br /> Y Owner/Operator Phone# <br /> G Contractor Name A,r(4,✓dl Phone# 0-41k, -u 6--1 zti6 <br /> O <br /> T Contractor Address I W I/.A (o CA Lle# - Class <br /> MLM yN <br /> A <br /> Insurer ,, ,U ,clrFla >. far )-1- Work Comp# <br /> C ' <br /> ICC Technicians Name <br /> T l yr N Ln u-?— u 7 Expiration Date y <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> o.e.erplpinp sump,of lwkn r,Uno to„�m,I Installed <br /> T <br /> A <br /> N <br /> K <br /> P J n Approvetl .__.._ Approved with conditions �. Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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 SHAD„NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCa OF TFI WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA,^ -f <br /> Applla nt'9 Slgnatum Title Dale l <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 /> NAME l.L TITLE (7p/-"A" "4, `PHONE# <br /> ADDRESS I t/D W /G�-1�.*u /4i 6ibr S7-36 4*9U /-d q-J`'F�O <br /> SIGNATURE DATE <br /> EH230038(revised 02I20109) <br /> i <br />