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ENVIRONMI RTAL HEALTH DEVARTMENT <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 ❑PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT L&LD START/EVR UPGRADE <br /> FA EPA Site# Project Contact&Telephone# I Suh _ _37 2 <br /> 'C Facility Name 1 G �� Phone# U0 ..j�— <br /> � <br /> Address <br /> Vl� <br /> T <br /> Cross Street <br /> Y Owner/Operator P Phone# <br /> o Contractor Name I j Phone# Z-0 6ZY_ ro <br /> N Contractor Addres <br /> a CALic# Class <br /> A Insurer Work Comp# DOD —2c>-r <br /> T ICC Technicians Certification Number <br /> T ' ZS Z Expiration Date / <br /> R ICC Installer's Certification Number (� <br /> � 7jZ Expiration Date 910700 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑ApprovedI�Approved with conditions ❑Disapproved <br /> L (S Attachment With Conditions) <br /> A ��l v� <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 COMPENSATION LAWS OF C RNIA." CONTRACTOR'S HIRING OR BCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PER RMANCE OFT 0 FOR CH THIS PERMIT IS ISSUE ,I S AL EMPLOY PERSONS SUBJECT TO W RKER'S COMPENSATION LAWS <br /> OF CALIFORNIA."\- <br /> Applicants Signature Title Date y <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 desig ated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibili f e bil fig by gnaturetAcd, e below. 3 /��jNAME L TITLE PHONE# W� �/ V <br /> ADDRESS �6h 64VIIAvl.... <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />