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Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN 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 PERMIT TYPE <br /> ` W <br /> BELO <br /> UTANK RETROFIT ULI <br /> PIPING REPAIRIRETROFIT UDC REPAI ETRO T <br /> I~ EPA Site# Project Contact&Telephone# �- <br /> C Facility Name 3 04 C4Phone# - 2' <br /> I <br /> L Address y <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone#a09 lf5 -9?-29 <br /> O <br /> Contractor Name (J�� Phone# <br /> F Contractor Address CA Uc# Class 8,C46 <br /> z <br /> AInsurer I r+ - Work Camp# j "��]�(S <br /> TICC Technician's Certification Number - Expiration Date I <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> CurrenttyfPreviously <br /> T <br /> A <br /> k <br /> K <br /> P pproved UApproved with conditions UOisapproved <br /> L (See Attachment With Conditions) <br /> A n� <br /> N Plan Reviewers Name Da.--E/ <br /> / G <br /> 04 <br /> APPL-ICANT MUST PERFORM ALL WORK IN ACCORDANCE Wma SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DCPARTMFNT.OWNER OR 1-16RISED AGENT'S SIGNATURE CERTIFIES THE FOLLOWNG: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE VVORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MARINER AS TO BECOME SUBJECT TO <br /> WORKERS COMPENSATIM LAWS OF CALIFORNIA." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM OF THE VWRK FOR WHICH THIS PERMIT I SHALL EM OY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OFCALJFORNIA" <br /> ApplicantsSignatise (/ T <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 pemtit applicant, e.g. property owner, the party must acknowledge this <br /> respo sib" or Ing y sign Lure and date below_ <br /> NA "r ��c'/ TITL PHONE <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 818106) <br />