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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN 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 /> UTANK RETRORT UPIPING REPAMETROFIT UuDc REPAIR/RETRORT <br /> F EPA Site# Project Contact&Telephone# <br /> � I e �%' !- L-�3r3 <br /> AL+ <br /> C Facility Name U, c o i? 6/`1i� -t4wie-li Phone# <br /> Address L S' CIA f5imWip <br /> I Cross Street <br /> Y Owner/Operator h `r !p A <br /> Phone# �o9- ,7 — /S�3 <br /> Co Contractor Name �'� �.z ' L— Phone#. 9- 411,�— 6337 <br /> T Contractor Addresst+ 3S (�r� CA is# ClassA C //O #A <br /> A Insure! �-py la.►7 lit►' work Comp# /7;73 <br /> G <br /> T ICC Technician's Certification Number ExpirationExpirationDate <br /> o <br /> R ICC InstalkWs Certification Number ExpirationExpirationDate <br /> Tank ID# Tank Size Chemicals Stared Date UST Instal}ed <br /> Currently/Previously <br /> T <br /> A <br /> u <br /> K <br /> P LIApproved Approved with conditions UDisapproved <br /> L /(See Atta <br /> chment With Conditions) <br /> N Plan Reviewers Name Data <br /> APPLICANT MUST PERFORU ALL WW_LILA -VATB.SAN JOAQMCGLZITY CRDMbJ F—S STATE LAWS AhIaR ILES AZ D.REGLILATIONS OF SAN <br /> JOACIUN COUNTY.EwRoNmEwrAL HEALTH DEPARTMENT.OWNER OR LCBIsED AGENTS SG ATURE CERTIFIES THE FOLLOWING_ -1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WCRK FCR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUC3"i A 16W4 R AS TO BECOME SLIRJECT TO <br /> vVCJRKER-S COW-194SATKJN LAWS OF CALIFORNIA- CONTRA[TCR'S HIRING OR SIGNATURE CERTIFIES THE FOLLJOW01I` -1 CERTIFY <br /> THAT W THE PERFORMANCE OF THE WORK FOR W-IIQ-I THIS PERMIT IS ISSLED.I SHALL EMPLOY PERSONS SIJB-ECT TO V 0RKEFZS COMPENSATION LAWS <br /> CF CALIFORNIA"' 7 <br /> q is �e -die.`) ;-(e';et' l.L>43r,�1�,.J�GY Dere / ":3'Q <br /> BIWNG INFORMATION: <br /> indicate the responsible party to be billed for additional EHD staff tine expended beyond permit payment coverage per tank tf <br /> the party designated below is different than the permit applicant, e.g_ property owner, the party must admowledge this <br /> responsibility for the billing by signature and date below. /�1l� <br /> NAME t' �LC[o T1TLE.�ra�a�,cC (Dila//ty�Y PHONE:,�D9 —T�/'�`33 r] <br /> ADDRESS .25-3S ILC?CcXLM lr �JTC«r v1 C' GI S <br /> SIGNATURE -1 <br /> EH23DO38(revised 8/8✓06) <br /> 1 <br />