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n / <br />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: <br />TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # - _1 <br />C <br />_ Phone # _ r' - 1-1111 <br />Facility Name V <br />I <br />L <br />L r T Address 2�''11 (� <br />kff my SIXY) <br />I <br />'014 <br />Cross Street <br />T <br />Y <br />Owner/Operator MRoc-h Lot, Phone -Irj <br />C <br />Contractor Name �; <br />Phone # -j <br />N <br />T <br />Contractor Address a&_Mn <br />CA Lic # �iQ L9 Class _� t <br />RInsurer <br />A <br />Work Comp # i _o <br />TICC <br />T <br />Technician's Certification Number <br />Expiration Date <br />RICC <br />R <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />onditions ❑Disapproved <br />Approved"JOAQUIN <br />L <br />itConditions) <br />A <br />N <br />Plan Reviewers NameDate IZ <br />APPLICANT MUST PERFORM! ALL WORK I ACCOINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AG S SIGNATURE CERTIFIES THE FOLLOWING: "1 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 FERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA."�M,, <br />�� <br />Applicants Signature .1 lY I 1 ! �Yl& 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 signature end date below. <br />NAME TITLE \(Q J PHONE # 2Aq !!jj fiI ( _ <br />ADDRE-SS2 (Li t1� l 1�iJ r�I\I ., �� LV�li�ily) _0p • ` , 57G! <br />SIGNATURE Yom) OJA& <br />EH230038 (revised 8/8/06) <br />