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4 JblLo7Cl�h[ - <br /> 0 • <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 TYPEBELOW. <br /> OTANK RETROFIT ❑PIPING REPAIFJRETROFIT OIIDC REPAIRIAETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name (c, amici{.,c � 'c c Phone# -Z p <br /> I <br /> L Address <br /> I Cross Street <br /> T II / <br /> Y OwneNOperatOr (l �c.� ��t B 'rJtr:..,_._.. Phone III <br /> D Contractor Name - <br /> o Tt_ E l i e 5c< f�+{x�y Phone# <br /> N <br /> r Contractor Address CALic# Class <br /> A Insurer Work Comp# <br /> G ICC Technician's Certification Number <br /> Y Expiration Date <br /> DICC Installer's Certification Number <br /> R_ Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Dale UST Installed <br /> Currentl&reviously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A LS�O� <br /> N Plan Reviewers Name DaI.—az <br /> _ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN 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 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> A*canls Si"un 1I9e Dole <br /> BILLING INFORMATION: <br /> Indicate the re6poneible party to be billed for additional EHD staff time expended beyond permit payment coverage per lank. If <br /> the party designated below is different than the permit applitanl, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Pam". I L ;..,G?TI4kTITLE J PHONE# <br /> ADDRESS ` Lr•.W.� 1..�?�l `.r�i- t�-( _. <br /> SII3NATUR <br /> EH210038(revised N6106) <br /> 8 d fitR (C (779C P,nj/1 ( : ) 1. ' IS/Al : l ( 1007 L7 M r( (N lJAJ IAICH <br />