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ENVIRONMENTAL HEALTH DEPARTMENT <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 />F-1 D-1 -- -o TonMT ]UCnI n START/FVR UPGRADE <br />F <br />LJ <br />EPA Site # Project Contact & Telephone # <br />� <br />Facility Name c i (p Phone # {,�-� / �� <br />IAddress <br />L <br />'moi Oe.II f&AfJ <br />ICross <br />Street <br />T <br />Y <br />Owner/Operator Phone # i / Otto <br />C <br />Contractor Name A �s j�ao la"Cgs IIf�Lt., <br />Phone #-4C:74, (45711B. Co <br />T <br />Contractor Address?p, Y 2O <br />CA Lic # �! Class C <br />R <br />A <br />Insurer <br />Work Comp # <br />T <br />ICC Technician's Certification Number �(O3 -U� <br />Expiration Date -� ! �j (�j/O <br />Q <br />ICC Installer's Certification Number f52-5- e0- 01 <br />Expiration Date S 8 �Z <br />R <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />A <br />ltd OL'D <br />R <br />K <br />❑Approved Approved with conditions ❑Disapproved <br />P <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date3 U1S <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 CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF OO=FORHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />)TH <br />OF CALIFORNIA.",I �VI/1 / �, (!. T riP�l�[%) Date <br />BILLING INFORMATION: <br />Indicate the rEsponsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. I <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for <br />the billing, by <br />signature and date below. <br />I � _ <br />PHONE# � <br />� <br />NAME TITLE FCA�+� <br />SIGNA <br />EH230038 (rbviso 12/31/07) <br />1 <br />