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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 BELOW. <br />TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />APhone <br />C <br />Facility Name U$ 116 <br /># 4Yb <br />Address <br />TCross <br />Street rek fo <br />Y <br />Owner/Operator Clo,"Okq <br />Phone # -41 16 -9 2 <br />G <br />O <br />Contractor Name �'7 nde,�cn i'irnE (,o <br />Phone# O 44,g;?- 573 <br />N <br />T <br />Contractor Address p / s <br />CALic# $5(677 Class <br />R <br />Insurer + F <br />Work Comp # (J 60 6 <br />T <br />ICC Technician's Certification Number ,f'Z S7�f 2 3 - U T <br />Expiration Date , 30 -pi <br />R <br />ICC Installer's Certification Number r?Zq7-A—CAr <br />Expiration Date 1-30-07 <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />❑Approved ❑Disapproved <br />P <br />eKpproved with conditions <br />L <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name Dated <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 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." \ <br />ApplicantsSignature Tille //f jn Date I 1 — ? <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 />EH230038 (revised 8/8/06) <br />