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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 /> ANK RETROFIT UPIPING REPAIR/RETROFIT I JUDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> D Facility Name fr Phone# <br /> I <br /> L Address <br /> I Cross Street 5 Nt7 <br /> T <br /> Y Owner/Operator N D J S St f Phone# <br /> C <br /> Contractor Name ✓ 0Q � LEUrN 1N ,Q1 /A.r, Phone#�'/(o —9,Y9-15 37 <br /> N Contractor Address p @o ic a s I CA Lic# 3 Class _ Z <br /> R Insurer Work Comp# 0074e 0-C7 ^ <br /> TICC Technician's Certification Number Expiration Date <br /> R ICC Installer's Certification Number $2 s'-Z-24 i I Expiration Date 1 — f ( — O 7 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T f Slav CyyL_ n /udly' <br /> A <br /> N <br /> K <br /> P UApproved AVWO,,d with conditions UDisapproved <br /> L (See Attachment With Conditions) <br /> A 1 (/ <br /> N Plan Reviewers NameDate <br /> —/— S—0 <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 5 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 /> WORKERS 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 WORKERS COMPENSATION LAWS <br /> OF CAUFORNIA' p <br /> Applicants Skmature T91e �Ta— Date O ' �C' by <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�,sign ature and d�1(g/ty�o�bel onw. <br /> 1 f NAME �1rj419 eh j4� 1'n^`ti' CTIT`LE� PHONE}# ��' ! -'2 2 9 2 <br /> / ADDRESS 1 /1 �1 I 1V�I i l�f --Arf ` fir" C, R' �} S^c�C o Cl <br /> SIGNATURE Jct <br /> EH230038(revised 8/8W <br /> 1 <br />