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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 TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name L-DJE if) L Phone# 2 Dq -S54 4(D <br /> I Address 155 5 ML900 <br /> TCross Street <br /> Y Owner/Operator �' 1� Phone# `-t� 5 ( - ( 7 <br /> C Contractor Name ALPAA �� � I� Phone _(08-YAM <br /> N <br /> T Contractor Address Q, �1� � CA Lic# 21 2_42_ IQIQ Class <br /> R <br /> A Insurer M-LIP— .J Work Comp#L)i7 j29K1-I ,_ <br /> TICC Technician's Certification Number Expiration Date <br /> RICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T _59CW1N0G2Lq05 651- S 2D. CIGO I��VI;A�2 OE�J <br /> N 3q 5\l0 S2GQ OSSLllOocu OE6 <br /> KOSSv <br /> 3010�5ttQrC->2j_Q051,;S -M boo �D(Es. <br /> P ❑Approved L�Kpproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A 1d <br /> � � / <br /> N Plan Reviewers Name �'�✓� Vim'` N�/\. /"` Date ��JZ (, / <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 SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title Date <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 /> NAME1' l TITLE PHONE#� "lS��— CJ�� <br /> ADDRESS �' � Qkxo�-c <br /> i <br /> SIGNATURE <br /> ]�A49J& <br /> EH230038 revisedV13107) <br /> 1 <br />