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07/02/2008 WED 12: 13 FAX 0002/004 <br /> 07/02/2008 WED 11: 57 FAX 20 3433 SJC ERD . 12002/004 <br /> i <br /> 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 /> THIr <br /> S PERMIT EXPIRES 180 DAYS FROM THE APPROVAAL77 DATE. INDICATE PERMIT TYPE BELOW: <br /> I� <br /> �I LJTANK RETROFIT (]PIPING REPAIR/RETROFIT I...JUDC REPAIPJRETRORT COLD START/EVR UPGRADE <br /> F EPA Site At Project Contact&Telephone# <br /> A <br /> C Facility Name T()1. FA7E J blvv+-&8`(� Phone#%( ` 1 716Z edit. <br /> � Address 14Mb )�- ` �Q t-A. <br /> T Cross Street <br /> i <br /> Y Owner/Operator im" — 8r?Ao G kj&(1q/ Phone# cif 006 --7e)(6 <br /> o Contractor Name � one9 g7Q- }jodO <br /> 1 T Contractor Address I .yPX t' I.�atvAaAznt�r. CA Lie# Class <br /> R <br /> A Insurer t_Lao s_ Ccs work Comp# WA-71,01 R x-177 17 <br /> ICC Technician's Cerdflcation Number 5L-tE- St&( )4 kr14L- ?AILjL Expiration Dale SkO L <br /> D ICC Installer's Certification Number Expiration Date VA <br /> R <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T..... . . . ... . ......_. <br /> A <br /> N <br /> K <br /> P DApproved t#Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A ^� ) <br /> N Plan Reviewers Name K'� CDate <br /> _APPLICAN_T MUST PERFORM ALL WORK IN A_gCOR,pANG.E\"fLTH SAN JOAOUIN COUNTY_OROINANCES,_STATE.LAWS,-AND..RULES..AND..REGULATIONSOF.SAN....._.__.._.__. <br /> '-� JOAOUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS 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 OFT WOR FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature <br /> BILLING INFOR ATION: <br /> Indicate the responsible party to be billed for additional EHO 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. y q` /�«7 <br /> NAME ���i'.c, / J/Zoo-cIS TITLE ^^-Le1a /� 7 . �yy cePHONEE# A3 <br /> n//,Cis /0-3d?FC) <br /> ADDRESS ��I R U A L /V'l! 'SAP YUP—Y,GIY�c w-''1 L/ C14 <br /> I <br /> SIGNATURE <br /> EH230038(revised 12131/07) <br /> ------------- <br /> 1 <br />