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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 i'HE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> ANK RETROFIT <br /> i. .,PIPING REPAIR/RETROFIT :_ UDC REPAIPJRETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name / 1 11 2�1 ✓ _. Phone# <br /> � Address y' <br /> I Cross Street <br /> T <br /> Y Owner/Operator <br /> o Contractor Name Phone# <br /> N <br /> ContractorAddress <br /> jw/L� � CA Lic#s ' 3 Class <br /> R err-.K_ el — __�- - <br /> C Insurer. ___._— Work Comp# U j ! <br /> T ICC Technician's Certification Number L" Expiration Date �. <br /> DICC Installer's Certification Number 7 r <br /> Rte. _. Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> IN <br /> K <br /> AT ._]Approved Approved with conditions Y Disapproved <br /> (See Attachment With Conditions) <br /> �� /� <br /> Reviewers NameDate— <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE NTH 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: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT'T'O WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature <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. <br /> NAME' <br /> ADDRESS, 1f � Jf�.r�l��" /"f'"n� X' ^i'�' LK''e�3�✓-�c. '1J - ./K"�.ra J�.�.-L� �s"7h''.� <br /> ✓l. <br /> EH230dii(revised 8/8/06) <br /> 1 I <br /> gooin 'IV,LNMMONIANH SIV,L TTOTS29916 %Vd 6Z:9T 9009/90/TT <br />