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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: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT LIUDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A Facility Name U_q_ Cl -.(✓N L- cx t iti /J.$ Phone# _3U`Z `�Z��i 9 I. <br /> L Address -70 -7G7= t1 UJ<2 u..,i <br /> I Cross Street : <br /> T b <br /> Y Owner/Operator ,r, �Q L' Phone# ),IJcj q �, _j <br /> o Contractor Name �hstC.� --SA'C-IL Phone# 'o! 4(Q+ _ 3 <br /> N Contractor Addres <br /> T s '�,CJ wt ( �,fir•\ �.� CA Lie# & 00 -7(o Class <br /> A Insurer Yt °C_f. /,.,y;. 8D Work Comp# - p -7•790 <br /> T ICC Technician's Certification Number _ rt _ 3 Expiration Date <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P, ❑ApprovedApproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A p <br /> N Plan Reviewers Namg 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 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" 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 SUJ CT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature 'L �^ Title i 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 FVC,ti tsC ITLE O:. C+ 1 PHONE# O"( XT' 3 U S�I <br /> ADDRESS rl'ES? rK I'1 t:r Lf--"q Tv'Ct 4A�, �C:( `-05�C. <br /> SIGNATURE"� l�li'-c.-t.--�._�'.�..m, <br /> EH230038(revised 12/31/07) <br /> 1 <br />