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05,122/2009 14: 43 6613933523 CHUCK HILL PAGE 03:''1, <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 Last 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 P-RV,,(T EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ r-OLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#(24--.01c <br /> Facility Name //�l�e r. o Phone# Z <br /> I, <br /> Address /� <br /> Cross Street <br /> T / <br /> Y Owner/Operator Phone# �O�-y�G-9516 <br /> CContractor Name Cam /,"cin G Phone# <br /> N Contractor Address /Ddf 9, ;// Q� S�„ ePr. 9YDe4 CA Lie# O yd Class <br /> R <br /> A ffu�sInsurer /! SSS. o, Work Comp# ? <br /> d -s �cl� C <br /> cICC Technician's Name Expiration Date 6- -O <br /> T <br /> R <br /> ICC Installer's Name Expiratlon Date <br /> Tank system work area Tank SIze Chemicals Stored Currently Date UST <br /> (I o 37 pipinq sumo,91 leak detocror,(Joc 112,Me.) Installed <br /> T <br /> A <br /> N <br /> K <br /> I <br /> P ❑ Approved pproved with conditions U Disapproved <br /> L (See Attachment with Conditions) <br /> � A ,/� <br /> N Plan Reviewers Name �' rI Date �- `T <br /> APPLICANT MUST PERFORM AU.WORK IN ACCO, DAN. WITH SAN JOAQUIN COUNTY-j0DINANCES.STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQIJIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR I.ICRNSED AGENT'S SIGNATURE CERTTFI6S TI IF_rOLLOWINO: "I CRTIFY 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 SU3JECT <br /> TO WORKER'S COMPENSATION LAWS OF CAI-IrORNIA." 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 /> Or <br /> CALIFORNIA." <br /> A <br /> Applicant's Sigtllture Title � Ia/)G .1114/—• Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed fpr additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permlt applicant, e.g. property owner, the party must acknowledge this <br /> responsibility//for the billing by signature and date below. <br /> NAME Cna._c!G /7�!/ TITLE eQ� r'�ifcC� PH0NE4 <br /> ADDRESS <br /> SIGNATURE / DATE r ~� <br /> EH230038(revised 02120109) <br /> 1 <br />