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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: Atavl "4W60 <br /> ��77 '' // <br /> 9944CAS %I%- rASTAT1 WO <br /> IJTANK RETROFIT LIPIPING REPAIR/RETROFIT OUDC REPAIR/RETROFIT L17COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#MK.' a.13 <br /> A Facility Name Phone# . <br /> C Y Frt FI.SLTl.IG R rr. 4 ZO - <br /> Address oy <br /> I Cross Sires <br /> T t yLTa <br /> y Owner/Operator M,Gvt it L LF, Phone# y„oq- jq2.. 15 f, <br /> C <br /> Contractor Name lar: Phone#S/p- U -1S10 103 <br /> T Contractor Addressa�pp,fir A �� CA 4 ? CA Lic# 7 oq Clas `I <br /> A Insurer s-r^n FL,ap Work Comp# f g S 457 1 -3_b0 <br /> T ICC Technician's Certification Number Expiration Date <br /> oICC Installer's Certification Number Expiration Date <br /> R 5-t� A cove S p <br /> Tank ID# Tank Size Chemicals Stored Date Date UST Installed <br /> T QJ000 u Ao ,Ns 10 - 9 ) <br /> A <br /> N J <br /> K I pod 1.0I -9 I <br /> P FJApproved proved with conditions LIDisapproved <br /> L (S Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date S <br /> APPLICANT MUST PERFORM ALL WO —IN ACCOROANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER M 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." CONTRACTORS 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 /> Applicants SigmitureA4Z Title 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 parry 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 M14",54 Aid QAA1 TITLE PHONE#Sl0•LI4•B39D Ex,103 <br /> ADDRESS ?CCS. V 11LIJAM St[tttySAII L1ANQnq CA 99577 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />