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RECEIVED <br /> POR 19 2017 <br /> ENVIRONMENTAL ¢ 4ri <br /> ENVIRONMENTAL HEALTH DEPPR Ml <br /> SAN JOAQUINCOUNTY rEa 2 i 2017 <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> „(I Al— <br /> Telephone:(209)468-3420 Fax: (209)468-3433 (','-'s � <br /> 1 <br /> Ir.nLlCe TtA-.NT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 00 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> CITANKRETROFIT OPIPING REPAIRIRETROFIT puoc REPAIRIRETROFIT f <br /> F EPA Site# �r Project Contact&Telephone# <br /> C Facility Name G „u Phone# <br /> � Address -a-775 r L 11,0 -z C 0 ! <br /> T Cross Street Lo. G D {I <br /> Y OwneriOperator Phone# - <br /> o contractor Name 1/' Arae(6C 1� Phone# 916 <br /> N Contractor Address TO 1117 Class <br /> R Insurer i ("syn WQrkCDmp#�07�907S.90 <br /> ICC Technician's Cedification Number `. 5��/ Expiration Date /, J I <br /> o <br /> R ICC Installers Certification Number Explration Date <br /> Tank ID# Tank Size Chemicals Stored pate UST Installed ' <br /> CurrentlyfPreviously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved Approvedwilhconditions [Disapproved <br /> L (S e A chment With Conditions) <br /> A <br /> N Plan Reviewers Name ' 1 l t I /J Date r S <br /> I <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' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY I <br /> THAT IN THE PERFORM CE OF THE WORK FOR WHICH THIS PERMIT IS`ISSUED,1'SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OFCALIFORNIA.° .... <br /> APPIlMnis si8nelure GC Ti9e (..2Ylv�"N'/ �— Dale ^ �-- <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 -t+d�e..�-�sLT J+u� L-A TITL \-Q'r 0 _--aS�iPHONECP_�nq IL <br /> IKO Oat-(�� <br /> ADDRESS C(4 <br /> SIGNATURE <br /> EH230038(revised 8/8109) I j <br /> t i i <br />