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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 /> n THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> LJTANK RETROFIT PIPING REPAIR/RETROFrr ,JDC REPAIR/RETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#ZW_ 51FZ <br /> � Facility Nam ;ff V zoe ; Phone# Qf <br /> Address A �S <br /> TCross Street <br /> Y Owner/Operator Phone#246 -C7- 5-7—W/., <br /> C Contractor Name Phone#,W-40 —6 <br /> Q <br /> N <br /> T Contractor Address W1, CA Lic#gu Class <br /> A Insurer >'Pr�� Work Comp# {/Z //4 <br /> C <br /> T ICC Technician's 4tification Number Expiration Date <br /> R ICC Installer's Certification Number 2 r' Expiration Date f <br /> R <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A /GG <br /> N <br /> K <br /> P ❑Approved Approved With conditions []Disapproved <br /> L �vryv"" (S Attachment With Conditions) <br /> A �0 2 <br /> N Plan Reviewers Name 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 AGENTS 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 WHICHTHISPERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATIONLAWS <br /> OF CALIFORNIA." <br /> r � <br /> Applicarrts S' lure 1 Tide�1 / Y 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 a 11 ant, e.g. grope owner the party must acknowledge this <br /> responsibility for the <br /> /billing by signature and da�tee�belgw 'Pat1A1AX 7 <br /> /c0� CC77/TITLE��.NJ'-/�IJZ6O✓ PHONE# YaS <br /> ADDRESS � <br /> SIG TURE f _ <br /> EH230038(revised 12131/07) <br /> 1 <br />