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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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPEBELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT KUDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# Michelle le (209) 602-7038 <br /> A <br /> Facility Name PG&E Stockton Service Center Phone# <br /> I Address 4040 West Lane Stockton CA <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> cContractor NameArmir en pmenPhone# (707 437-6668 <br /> N Contractor Address FOBQx 507 Vacaville CA 95696-0507 I CA Lic#498721 ClassA HAZ C10 <br /> T <br /> R tial Work Comp#aH=58500 <br /> G ICC Technician's Certification Number 5252367-II' 526432640' Expiration Date 2-4-09 7-26--09 <br /> T <br /> o <br /> R ICC Installer's Certification Number 5252367-M 108326140 Expiration Date 2-&-09 4-5-09 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved ,N1pproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date */2,/0-7 <br /> APPLICANT MUST PERFORM ALL i®RK 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 PE ITIS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFO NIA." _TRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF HE W THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicants Signature Tire Contractor Date 12-06-07 <br /> 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 Michael AArmour TITLE Prec;rlenr PHONE# (707) 437-6668 <br /> ADDRESS PO BOX 507 V vine 5696-0507 <br /> SIGNATURE <br /> EH230038(revised 8/3/07) <br /> 1 <br />