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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 ❑UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# RLoeobkkaw lot-aI164631 <br /> A <br /> C Facility Name SO4 0 Phone#,26 <br /> � Address 1S 64 W l[+t% Stl YC� q C k q 53 �0 <br /> T Cross Street Cc r-VC( qouto w <br /> Y Owner/Operator s}-cwL F C Phone# 9 a S r a-101 <br /> C Contractor Name Abp } 1 �Q �t,� 1,�L Phone# 40? U1� _ (PU3 $ <br /> T Contractor Address '3 QL Q WLR; CA Lic# 313-744- Class la,1q.Ci0,#A <br /> A Insurer <br /> Work Comp# \N I <br /> T ICC Technician's Certification Number $' S — U t Expiration Date (F acQ <br /> R ICC Installer's Certification Number $a, Sof- LST" Expiration Date -�-ta/ �,pp <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P pproved Approved with conditions LIDisapproved <br /> L (Se Attachment With Conditions) <br /> A4aA <br /> N Plan Reviewers Name 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 SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature • L,LbCr � Title `V L6 fky�V o <br /> Date 0 <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 TITLEII�.Gt�� d'LUrti'PYr PHONE# <br /> ADDRESS 4w L��ll /`V�le S6-,',LVOuZ CA (S1( 1 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />