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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 PERMITEXPIRES neo DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> L�TANK RETROFIT `PIPING REPAIR/RETROFIT ZUDC REPAIR/RETROFIT UCOLp START/EVP,UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> 0 Facility Name �� Phone# „20<-1.6 U 6—3 S� <br /> Address / �. S�oG 7`0 �/ rzb <br /> 'I" <br /> Cross Street <br /> Y Owner/Operator Phone# <br /> C Contractor Name _ <br /> Ca Phone# ,e l <br /> N Contractor Address <br /> .s CA Llc# 90 y3 Class <br /> R <br /> AInsurer <br /> Work Comp <br /> ICC Technician's Certification umber <br /> S�r;a0 5-S'-�e��477- Expiration Date <br /> ICC installer's Certification Numb <br /> R erO E-7f 9+/ _ Expiration Date <br /> Tank ID# Tank Size Chemicals Stared Data UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> K <br /> EN L�Approved Approved with conditions �JDisapproved <br /> (See Attachment With Conditions) <br /> Plan Reviewers Name <br /> Date Q <br /> APPLICANT MUST PERFORM ALL WORK ACCORDANCE W17H SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS Oh SAN <br /> JOAQUIN COUNTY. ENVIRONMENTAL HEALTH DEPARTMFNT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 16SUED,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'r0 WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature_ Title Date_ <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>V date below. / <br /> NAM) C� 1'I7LE r� O rl s �9 /'• PHONE# d l�O �"1�7 yU459 <br /> A0DIZES5 2 Y0 O <br /> 51GNATURE <br /> EI-1230038(revised 12131107) <br /> 1 <br /> 90/'b0 39tid -nIH >13111-10 6ZS6666Z99 ZZ :ZZ 1300Z//Z0/90 <br />