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FEB. 26. 2008012 : 26PW AG SPWS JET CTRntal 832-6152 Na, 64317 P. 1!' <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 EsaM Main erect, Stockton, California 952o2 <br /> Teleph;)ne: (209) 465-3420 Fax-, (209) 465-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TI-41S PERMIT CXPIRi a 18o DAYS FROM THE APPROVAL <br /> 'DATE. INDICATE PERMIT TYPEBELOW: <br /> I .ITANK RETROFIT _ PIPING RIEPAIRIRETROFIT L.JUDC REPAIFJRETROFIT UCOLD&TARTIEVR UPORADL <br /> FFEPA Site#C �,, QJ + Project Contact&Telephone# r <br /> C Faollity Name Phonea <br /> L Address <br /> I Cross Street <br /> Y gwnerlOperator 1g Phone ` r <br /> C Contractor Name <br /> 7`t'S TO C, . Phone# jlr f )� <br /> T ContractorAddraea'P-?3 <br /> . cj �*;�L'.t" :;1•C, l dor , CA tic ( Class '[� <br /> A •�'--- <br /> C a G', Worst Comp#a 7. r I, <br /> T ICC Techrticlan'R Cortlticatlon Number Expiration Qate <br /> 0 1CC Ins4aller's Certification hlumber '^���" '' � c. � ,r <br /> R r' 47 � � Explrallon Data <br /> Tank ID# Tank Size Chemleala Stored Date UST Inatalled <br /> Curronliy)Previously <br /> eT <br /> N <br /> K <br /> P tApproved _ -Approved ulllh conditions nDisapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name a- pato <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIFRONMENTAI, 14EnL711 Drf'ARrMENT. OWNER OR LICENSED AGENTS SIGNATURE CURTIFIES THE FOLLOWING; "d CERTIFY'THAT IN <br /> THE PERFORMANCE of THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN$UCH A MANNER A$TO BECOME SUBJECT TO <br /> WORKERS COMPENSATION LAWS of GALIFORNIA," CONTpAo701{'S HIRING OR sUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERI ORMANCE OF THE WORK FOR WHICH I'HIS PEFMII'IS ISSUEL7,I SHALL EMPLOY PERSONS GU9JE3T TO WORKC-M3 CCMPEN$AT)ON LAWS <br /> OF CALIFOaNIA." /� fid ,�� <br /> AF Pflsanls 61gnaRure d ry_ bIr Tltl® I i" 11121 ! {�, 1 D®ie �Q 0 a <br /> BILLING INFORMATION, JJ <br /> Indicate the reaponsible party to be billed for additional EHD staff time expended beyond permit payment coverape per tank. If <br /> the party designated below is different than the permit applicant, e.g. properly owner, the party must acknowledged thle <br /> responsibility for the billing by Signatuulre and !date below, ��- <br /> NAME ?-f ��,a , Z ;/7 `�a /71�1`L f1r ,rI TITLE PHONE 0_OIL? 9OA- <br /> ADDREzss_- Jl� <br /> SIC7NA TLIHtF� <br /> EH230038(rovInod 121 71 <br />