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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 PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT COLD STARTIEVR UPGRADE <br /> F I EPA Site# Project Contact&Telephone# <br /> A %6 �� C) <br /> C Facility Name 'SAyj Phone W2- 7Z <br /> Address <br /> T 'Cross Street <br /> Y Owner/Operator Phone# <br /> cContractor Name y � � <br /> o V v. �� S L.l�S �•L Phone# c?;,& 70 <br /> T Contractor Address'-213J J EUjaZ& 7A) <br /> CA Lie#�Z j Z ., Glass A. (� <br /> R Insurer <br /> A L - �• t &P Work Comp# W 7 17 <br /> C <br /> T � <br /> ICC Technician's Certification Number 2ZUf I —Z-LT Expiration Date <br /> o 2[-/ <br /> ' <br /> ICC Installers Certification Number <br /> R 3g-7 7Z- j/-T Expiration Date lf� <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T i t,lam- ti e C l2-+zL-,,11-44, U VLIIZI <br /> A -'�- - - t P �� <br /> N <br /> K <br /> P ❑Approved AA <br /> pproved with conditions []Disapproved <br /> L chment With Conditions) <br /> A <br /> N Plan Reviewers Name Z Q <br /> a <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 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 E WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature pate r <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 /> ,+ <br /> NAME 1-11// / / j Si TITLE `_© )r< 12 PHONE# �I/ Q <br /> ADDRESS .Gf ✓r� r{,) t (GYQc4l0 (t2. J <br /> SIGNATURE <br /> EH230038(revised 12131107) <br /> 1 <br />