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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN COUNTY <br /> 304 East Weber Avenue,Third Floor,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 PERMrT TYPE BELOW <br /> UTANK RETROFIT UPiPING REPMURETRORT UUDC REPAIRR ETROFIT <br /> F I EPA Site# Project Contact&Telephone a# <br /> A <br /> C Facility Name Phone it. <br /> 1 Address r <br /> I Cross Street CA 9Y <br /> 64 <br /> T <br /> y Owner/Operator Phone# r <br /> Co Contractor Name 1 tw- 1 rackw Phone# <br /> 209- t/L/- 1.3 3 <br /> T Contractor Address CA Lic# <br /> S (� 076 /o Its <br /> R <br /> Insurer r <br /> rcL V1 fo v`X" Cwork Comp# O/-7 <br /> T JCC Technician's Certification Number <br /> T Expiration Data <br /> R ICC Installer's Certification Number <br /> 1_xpua-tion <br /> Data <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> u <br /> K <br /> P LIApproved 74proved with conditions UDisappmved <br /> L (See Attachment With Conditions) <br /> A l 1 <br /> N Plan Reviewers NameDate <br /> _ <br /> APPLICANT MUST PERFORM ALL WORK INACCORDANCEW[TH SAN JOALXMCOL;NTY OROGt�,STATE LAWS,AND,01 A D.REGLAATKINS OF SAN <br /> "CLAN COUNTY,ETrVIRONMENTAL HEALTH DEPARTMENT.OVVNER OR LIC8SSED AGENT'S SIGNATURE CERTIFIES THE FOLLOVRC: 'I CERTIFY THAT IN <br /> THE:PERFORMANCE OF THE WORK FOR WHK:H THIS PERMIT IS MSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A UN44ER AS TO BECOME,%a%ECT TO <br /> V4C*2KER'S C 3UPENSATION LAWS OF CALIFCRNVA." CONTRACTOR'S HIRING OR SLECONTRACTM SIGNATURE CERTWIES THE FCLL0",% : 'I CEIMFY <br /> THAT IN THE PE RFCRMANCE OF THE WORK FOR WHK]H THIS PERMIT 6 ISSN,I SHALL EMPLOY PERSONS SL&ECT TO NIM(EFrs COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> App5carts S+9 Mire Tdfe ? '(� � `'/i��/�1' Dote_ <br /> BILLING INFDRMATION: <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� syig�nature and date below. �� <br /> NAME 6"e Vf C Vl TITLESL�Wi(-`e 1Ird1&tf6fPHONE#�wy—�G� 41;j 3J <br /> ADDRESS )Sae <br /> SIGNATURE <br /> EH230038(revised 818M) <br /> 1 <br />