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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 REPAIRIRETROFIT OLD STTAART/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> D Facility Name s Phone#�Q►9 -7 <br /> 6 7-0 tax <br /> Address <br /> L o8 f�-�! <br /> I Cross Street Gw � <br /> T <br /> Y Owner/Operator �Z `b . i J" Phone# 204 dW <br /> cContractor Name S-��4��( Phone# 11(--, -70- -3 <br /> 0 <br /> T Contractor Address Z�j` eveQGKe�/J 1 CA Lic# 0 2I Z$�o Class p-eJp <br /> R Insurer J`: �\43�"YL'�1. AAI-LRAA , Work Comp# <br /> A <br /> T ICC Technician's Certification Number '525'Zp( It k Expiration Date <br /> R ICC Installer's Certification Number 5Z'3� ?j 2 P <br /> Ex iration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T l�`1l :�,1.v1: fqo C tC,,k- u <br /> K <br /> P ❑Appr ved Approved with conditions ❑Disapproved <br /> L (S Attachment With Conditions) <br /> N <br /> Plan Reviewers NameJA 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 ` "idle 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,�sig'naatuure and date below. /Ib <br /> NAME /Amt P� \t/ILVv� TITLE V n ' PHONE <br /> ADDRESS ZSft 0- �c( T L=L G'1 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />