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ENVIRONMENTAL HEALTH DEPXRTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor, Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> ��, II THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE <br /> I BELOW: <br /> IWTANK RETROFIT ❑PIPING REPAIFURETROFIT [IPEWC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# CAyk 7Y60 <br /> Facility Name j �'� c, Phone# z o''t-e/Y- 6�•7 y <br /> IL Address 70 .7 Y,211-_M'e- 14ve an/eltk-- Ca. S <br /> TCross Street <br /> Y Ovmer/operator Fru n n S ce a/• Phone# ,Z,o 9-X30 S S�. <br /> ° Contractor Name C-4w.7 ;0 Pr ec.i n 7" 11'r Phone# 66/ ' 36,3 • 7 D O <br /> ° CALX# �Y�f'/,r0 Class C6/ ,Q Yo <br /> T Contrador Address � G. 6Rbee <br /> k7 &.tl r93�-�O <br /> R Insurer EI/Gre WorkComp#AT ICC Technician's Certification Nr s0�7$ - U ]- Expiration Date <br /> R ICC Installer's Certification Number wd� 7��fY9" u1 Expiration Date ��/'Z,{ d <br /> Tank Size Chemicals Stored Date UST Installed <br /> Tank ID# Currently/Previously <br /> /o ocr7G.rl 7 GQ rad%n <br /> T <br /> A # ,S DOO'risl �T %a 11-n e- <br /> N <br /> K ar p00 A i ASN. <br /> pEjApproved with conditions []Disapproved <br /> L (See Attachment With Conditions) J <br /> N Plan Reviewers Name Date/ "-LzZ <br /> APPLICANT MUST PERFORM ALL RK 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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CAUFORNIN" A ��/e a 7 <br /> APlfcarLs Sgneture Tide d Gro id//•t f• Date <br /> tsiLLING 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 <br /> //by signature and date below. <br /> NAME C'h/- 4/ -TITLE PHONE# <br /> ADDRESS 1?d. IT-14e <br /> 3p <br /> SIGNATURE <br /> EH230038(revised SOW) <br /> 1 <br />