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_A <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQHN COUNTY <br /> 304 East Weber Avenue,Tkird 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 /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPEBELOWBELO <br /> UTANK RETROFIT UPiPING REPAWRETROFIT JUDC REPAIRMETRORT <br /> F EPA Site# Prefect Cantact&Telephone# ; C �>CI._ �(L I-L,33 <br /> A <br /> C FacilityElIaEmeEjh�' Phone# <br /> Addres <br /> I Cross Street <br /> T <br /> y Owner/Operator <br /> . Phone# ` <br /> C <br /> D Contracfror Name tL i {V x ck N' -L I'LL Phone# <br /> T Contractor Address <br /> c c,Y� r CA Inc# `o to U V Class BC (0 <br /> R _ <br /> A Insurer F �"�.`C dor c>v Work Comp# f 606 G <br /> T JGC Technician's Certification Number <br /> Expiration Date <br /> R JCC Installer's Certification Number <br /> F_xpira5orm Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currenty/Pneviously <br /> T <br /> A <br /> w <br /> K <br /> PL-lAppmved proved with conditions UDisapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N <br /> Plan Reviewers Namepath <br /> APPiJCANr MUST PERFORM AU WORK LKL 4GCOEDANCE WrM SAN JDAC UN COUNTY CRO LANCES,STATE LAVVS AND RULES ANO-REGIAATIGNS OF SAN <br /> JOACUIN CCC WY,EW RONME3•fTAL HEALTH M:PARTMENT.OWNER OR LKPISED AGENT'S SGNATLIRE CERTIFIES THE FOLLovjW: 'I CE2TIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FCR WHICH THIS PERMIT IS IS, <br /> UM,I SHALL NOT EMPLOY ANY PERSON W S)C H A MANNER AS TO BECOME SUBJECT TO <br /> WORKB7S COMPENSATION LAWS OF CAUFORNIA" CONTRACTOR'S WRING OR yLOCONTRACTM S)GNATURE CERTIFIES THE FOLL�: "1 CERTIFY <br /> THAT W THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS a)B ECT TO WOFRKEAS COWegSATION LAWS <br /> OF CALIFORNIA" <br /> AppFicarts Sgyiatire Tid- Date <br /> BILLING INFDRMATION: <br /> indicate the responsible party to be billed for additional EHD staff tine 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 bitting by signature and date below- <br /> NAM <br /> elow_ c L' <br /> NAME �_Lt.�lr �� lI 11 TIT1Eo V ILL CA - CC L 'V PHONE# <br /> ADDRESS c :��� �.l_J l�f LA <br /> SIGNATUREX �� <br /> EH23DO38(revised 8/8/06) <br /> 1 <br />