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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: ASOVII &"k6O <br /> 77 [/COLD <br /> 944LI CAS 47s- IM37MVl er0 <br /> OTANK RETROFIT UPIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT L17COLD START/EVR UPGRADE <br /> FEPA Site# Project Contact&Telephone#14 Sib-114-7530 <br /> A i " <br /> G Facility Name ;,, Cis kobruamr &W 11-f r-lw Phone# ,Zp <br /> � Address j q <br /> I Cross Streetyr.TD <br /> T <br /> Y Owner/Operatoi-jiAi N Phone# yoq_ 1- 15 6 <br /> o Contractor Name IN f Phone#S/o-U •BJf D Y+� I o3 <br /> IQ <br /> T Contractor Address�,�ev Wj TT CA Lic# oq Clas `1 e A <br /> lk <br /> A Insurer S-rP.Nt ia.1P Work Comp# -1D6 <br /> T ICC Technician's Certification Number SYE Expiration Date <br /> o <br /> R ICC Installer's Certification Number SF w Goer S Expiration Dale <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T QJ000UNWISS116 4h&,Lj1j3k / <br /> A <br /> N <br /> K <br /> P DApproved ❑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.OWNER OR LICENSED AGENTS 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 TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> Applkarlla S' naWre Title Dale <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per lank. 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 M/4d/7P1- 66,!/ Afi1 TITLE PHONE#6I0-LI4-9390 FxID3 <br /> ADDRESS 2COo WILJJAM/ 9NUIP?i SAO LSANor+o CA �I4577 <br /> SIGNATURE1�.—/I"i� <br /> EH230038(revised 12/31/07) <br /> 1 <br />