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ENVIRONMENTAL HEALTH DEPARTMENT <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 /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW:IJ <br /> UTANK RETROFIT ❑PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> G Facility Name 4 A G& 36 6 Phone# <br /> I ess Addr <br /> L Ll(_ <e f4(e r✓1q L, Ili, <br /> TCross Street Lae <br /> Y Owner/Operator �r e u.� Phone# <br /> o Contractor Name Phone# <br /> C - �i�rwitV n -Y4 7 T57 7 <br /> N <br /> R Contractor Address CA Lic# <br /> Class <br /> A Insurer Work Comp# lO,;p G <br /> TICC Technicians Certification Number <br /> T ' 6_30006 I -LAT Expiration Date <br /> 0 e,, o0 C <br /> R ICC Installer's Certification Number 5'2 g'7-01Z3 -UL Expiration Date � �j rco-? <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T V <br /> A <br /> N <br /> K <br /> P DApproved pproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A / <br /> N Plan Reviewers Nam vD <br /> ate <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: 111 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 f-C <br /> Date 7-- 7- Z - 67 <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 TITLE <br /> PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />