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RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENTP 1 6 zou <br /> SAN JOAQUIN COUNTY ENV'IROWAE1VT HEALTH <br /> 600 East Main Street, Stockton, California 95202 PERMIT/SERVICES <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 ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name 41 IZp6 Phone# ZO —45 <br /> I Address 164 rop <br /> I Cross Street W <br /> T <br /> Y Owner/Operator Q(S' Phone# ,5 _ 3 <br /> o Contractor Name E Phone# <br /> N ContractorAddreas C�27 CALicVC7792(w? Class <br /> T <br /> A Insurer twump ftmr Work Comp# <br /> QICC Technician's Certification Number 2.y _ Expiration Date 1 Q6 <br /> T <br /> D <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;00r) sl 1 OG smeeme <br /> A <br /> N <br /> K <br /> P []Approved ®Approved with conditions []Disapproved <br /> L (See Attachment With Conditions) <br /> A .` <br /> N Plan Reviewers Name (/ � r1,OLILAA- Date ID 27 10% <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: "1 CERTIFY <br /> THAT IN THE PERFORMA E OF THE WORK F ICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ��-/� <br /> Applicants Signature Tile"CSG12U (�C.J Date q—/5'-09' <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. f,, r^ <br /> NAME �.� SIS' -V jCf, TITLEG01V f/P� SS(Af—g nPHONE# ,�J`r'� /7-7O <br /> ADDRESS z7 N v J <br /> SIGNATURE <br /> EH230038(revised 12 1107) <br /> 1 <br />