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, 0 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQM 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 /> ❑TANK RETROFIT ❑PIPING REPAIWRETROFrr ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# 6 It 269 Z07-l"5 <br /> C Facility Name A N,c�\ � ` U - Phone# - 5 <br /> Address 4�5V 5. ` \ . <br /> I Cross Street <br /> T - - <br /> Y Owner/Operator 1 Phone# I --7 <br /> c Contractor Name '; Phone.# <br /> 0 <br /> Wq <br /> N Contractor Address bT&-K9Y) CA Lic# (, Class .� t <br /> T <br /> AInsurer Work Comp# -� <br /> Q 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 <br /> A <br /> N <br /> K <br /> P ❑Approved )/�/4/wroved with conditions ❑Disapproved <br /> L (Sde ent With Conditions) <br /> A <br /> N Plan Reviewers Name Date��/�� <br /> APPLICANT MUST PERFORM!ALL WORK IN ACCORD 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 SUBJECT 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 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS- <br /> OF CALIFORNIA.' <br /> Appfionts Signature <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff 4ime 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. 1 r <br /> NAME f)�M (LA) ), yprn' GENE <br /> TITLE_- �nSyC-A�T(K�A�I V 4 YJ'� .PHONE# /61 I <br /> ADDRESS /I�//� �� MVII �57 [1EN »S11L1]J1=.(�'- iCJI-Y . �lj,5 <br /> SIGNATURE ,ll l l l <br /> EH230038(revised 8/8(08) <br />