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FROM :B. Z.SERVICESTRTION MRINT "INCE FRX NO. :916 371 2540 9ug. 11 2006 01:23PM P5 <br /> 1 . — <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 9)DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE <br /> BELOW: <br /> TANK RETROFIT PIPING REPAIR/RETROFNXUDC REPAIR/RETROFIT <br /> . . ..._ ._ <br /> F EPA Site# �Projectontact&Telephone# <br /> C FacilityName �ry,� ( A,,� _ Phone# q '�'.. v <br /> Address 1"lS�g--lT `"l �1:0, <br /> Crass Street G <br /> y owner/Operator t[�• .Phone# <br /> ...—� .. .. ,,fin , , . ._ . ._. <br /> C Contractor Name NySYLLlLu17S1 .�V -YlCJU Phone# ' <br /> T Contractor Address G33, ��Dyk �(t,�?IGLfylpfliD _ CA Lic# Class. ._. <br /> A <br /> Insurer 9 � „• _ Work Camp# 0 � <br /> CICC Technician's Certification Number — Expiration Date ? <br /> RT ICC Installer _ <br /> 's Certification Number �, - I Expiration Date_ - /9/��. <br /> Tank ID# Tank Size Chemicals Stored pate UST Installed <br /> Curreutty/PreviouNy <br /> L'J'/�_- <br /> K <br /> P ❑Approved ClApproved With oonditione LJDisapproved <br /> L (See Attachment 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 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 SUNECT 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 SMALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> APPIkant,Signature TWaa. •�Y Data <br /> BILLING INFORMA N: <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 acknoveedge this <br /> responsibility for the billing by Signature and date below. <br /> NAME. TITLE PHONE# .•..,_. <br /> .._ ... ... <br /> ADDRESS ,_ <br /> SIGNATURE - — <br /> EH230038(revi99d S/W06) <br /> 1 <br />