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03/•04/2016 01:45 FAX <br />Ia 002/003 <br />18/16/2006 10:52 2094E 33 EHD PAGE 92 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenne, 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 />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW' <br />TANK RETROFIT ❑PIPING REPWR/RETROPIT 161Um REPAimKiieTROFIT <br />F <br />EPA Site # Pro)eot Contact & Telephone # <br />Facility blame Phone — 7 <br />L <br />Address <br />TCross <br />Street <br />y <br />OwnarlOperstor Phone!(,Ce• �g <br />0 <br />Q <br />Contractor Name <br />N <br />r <br />Contractor Address �, n, r.� 3 p '8 3 3 GA I�ic # Class <br />R <br />A <br />Insurer Work Gorrip# <br />CICC <br />Terhnlcian'e Certification Number (�T weft Bat>>rE 1dc S ? U <br />o <br />R <br />ICC Installer's Certficetion Number Expiration Data <br />Tank ID # Tank Slze <br />Chemicals Stored Date UST Installed <br />Currently/Prevlously <br />T <br />A <br />N <br />K <br />LApproved ❑Approved with conditions 11Dlssppraved <br />p <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANGSS, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LIC6N$6P AGENTS SIGNATURE CERTIFIES TNS FOLLOWING "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE wORK FOR WHICH THIS PERMIT IS ISSUED. I $MALL NOT EMPLOY ANY PERSON IN aUGH A MANNER AS TO 9ECOME SUBJECT TO <br />WORKER'S COMP5NOATIQN LAWS OF C-A.LIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN TH6 PERFORMANCE OR THE WORK FOR WHICH THIS PERMIT IS ISSUSO, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S GOMPEN3ATION LAWS <br />OF CALIFORNIA.' <br />a v Do `D 7 4 d <br />Applicants SignaiQ <br />(/ BILLINLi INI-UKNIAI IUN: <br />Indicate the reapansible party to be Gilled for addltlonal EHD staff time expended beyond permit payment coverage per tank, if <br />the party designated below is different than the permit applicant, e_g_ property owner, the party must acknowledge this <br />responsibility ffor the billing by signature End date below. % <br />NAME J14,4zl� TITLEPHONE�1{�J��`a1��� <br />ADORES$ <br />42 <br />EH23003a (revised WB/05) <br />I <br />