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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 Last Main Stxeet, Stockton, Q'alifornia 95202 <br /> Telephone. (209) 468-3420 Fax; (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> �THI PERMIT( PIP.ES 180 DAYS FROM THE APPROVAL DATE. INDICATC OERM7 TYPE BELOW <br /> _ ANK RCTROFIT JFIPING REPAIR/RETROFITr UDC Rf PAIR/RETROFIT r1 <br /> F EPA Site# _ _1COLD START/EVR UPGRADE <br /> p Project Contact&Telephone t# rn• Z1X� <br /> C Faclllty Name t S <br /> � Address 3 Phone <br /> T <br /> Cross Street <br /> y Own r/ orator <br /> C Phone <br /> D Contractor Name <br /> N , Phone# � <br /> T Contractor Address fl ,� CA LIc# <br /> qua �6/ D a z <br /> R Clas <br /> A Insurer —� work Comp 6 <br /> O ICC Techniclan's Certification Numbe <br /> T Explratlon Dato <br /> 0 <br /> ICC Installer's CertIfICBtlon Number Expiration Date <br /> Tank ID 6 Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previousiy <br /> T <br /> N r <br /> I <br /> K c� <br /> P rJApprovod proved with conditions <br /> L L_IDisapprovod <br /> A (See ttachm t With Conditions) <br /> N _ <br /> Plan Reviewers Name Data <br /> APPLICANT MU?T PEt?FOP,M ALL RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAW',;,AND RULES AND R[GULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMEN HEAI,TH DEPARTMENT OWNER OP LICENSEO AGEN^S SIGNATURE CERTIFIES THC FOLLOWING: "I CCRTIFY 7 <br /> TI-IF PERFORMANCE OF TFIC WOR< OR WHICH TATS PERfv11T IS ISSUED, SHALL NOT EMPLOY ANY PERSON INC THAT IN <br /> WORKER',^ COMP �GZALIF TOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE IFOLeLOW NG:�9BCERTIF� <br /> THAT IN THE PER- -M CE 0 E WORK F WHICH ERMIT IS ISSUED,I SHALL CMP Y P- <br /> OP CALIFORNIA" LO PERSONS SJBJECT TO WORKER'S COMPENSATION LAWS <br /> Appllcenlp.Slpnalu t 2 <br /> TillF � 1, <br /> BILLING INF RMATION <br /> Indlcate the responsible party to be billed for additional EHD staff time expendod beyond permit payment coverage per tank. If <br /> rhe party designated below Is different than the permit applicant, e.g. property Owner, the party must acknowledge (his <br /> responsibility for the blilinp by Slgnature and date below <br /> NAM= TITLE �— 01C <br /> PI-ZONE 7f <br /> ADDRESS cfo� /Lf,-,, <br /> n"61230038 <br /> GNATUP.E <br /> „'�C�(r9%llsed 12/31/07) <br /> 1 <br />