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ENVIRONMEATTAL HEALTH DEP.-.RTMENT „; <br /> SAN JOAQUIN COUNTY FEB 21 2017 <br /> 304 East Weber Avenue,Third Floor,Stockton, California 95202 AL <br /> Telephone: (209)468-3420 Fax: (209)468-3433 nr{yT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES eo DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT UDC REPAIRIRETROFIT <br /> F EPA Site# 06V Project Contact&Telephone# <br /> � <br /> Facility Name C -3. oU Phone# a � <br /> I Address ',377 A)r LVQ � e s <br /> I Cross Street LL9• G .D <br /> T <br /> Y Owner/Operator f Phone# <br /> D Contractor Name Phone# <br /> t/' �' O[¢-G�i1 �'!L%lv(L���'fL1.G"�' /.1.�C� <br /> N Contractor Address �p '�j �. �' CALic# �'�`/�' Class l <br /> R Insurer z (e9s! rk Comp#gE)7�✓J7Sa0/ <br /> A <br /> C ICC Technician's Certification Numberj/ Expiration Date /_2 - f <br /> T <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chem; Stored Date UST Installed <br /> Current) Previously <br /> T <br /> A <br /> N <br /> K <br /> 71 <br /> i <br /> P ❑Approved []Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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.bWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITIS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECTTO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' COyyy.RACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM NCE OF THE WORK FOR WHICH THIS PERMIT(TISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.” / / y T� <br /> Applicants Signature (fes TigeBILLING INFORMATION: <br /> Indicate the responsible party to be /billed additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is diffn the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signatuate be!ow. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />