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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 /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT SPIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact 8 Telephone# <br /> � Facility Name Phone# 2o-7 — 2 S <br /> I <br /> L Address G..►"� <br /> I Cross Street <br /> Y Owner/Operator -S1, 1 IL+d'f— Phone <br /> e Contractor Named (� Phone# <br /> 0 <br /> N Contractor Address , a 6vol 6 9sr9 1 CA Lie# MZZ 3 Class <br /> T <br /> RInBUrer Work Comp# 3_j <br /> A <br /> D ICC Technician's Certification Number Expiration Date <br /> T <br /> o <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T 12 OdI) 1 <br /> A <br /> N <br /> K <br /> P ❑Approved proved with conditions ❑Disapproved <br /> L (SeeA chment With Conditions) <br /> A <br /> N Plan Reviewers Name ��`� / Date <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 COMPENSA LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFO N E OF THE WORK FOR IS PERMIT IS ISSUEDyf SHALL EMPLOY PERSONS SUBJECT TOW KER'S OMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Appii rrts Sigraturc TIM. Dale <br /> BILLIRG 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 /> NNASM�n I the si at�r d^ belo TITLEWIXPHONE <br /> ADDRESS 0,1 4C) <br /> 1 <br /> SIGNATURE <br /> EH230038 12/31/07) <br /> 1 <br />