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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN J OAQ U IN 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 /> UTANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A Phone# <br /> C Facility Name 'rl <br /> Address fj 4T�kIrCJ� KA4 ;eZC . <br /> ICross Street <br /> T Phone# A10`2L—5-11-G 0-G <br /> Y Owner/Operator <br /> C Contractor Name G sexviCe—S Phone# <br /> 0 <br /> N Contractor Address ;_ CA Lic# Class ac fA�-,� <br /> T <br /> A Insurer ` Ee -�p�F� " ltQ�'1(o33 Work Comp# <br /> c ICC Technician's Certification Number Expiration Date <br /> T <br /> °R ICC Installer's Certification Number Expiration Date <br /> Chemicals Stored Date UST Installed <br /> Tank ID# Tank Size Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved MApproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> I <br /> N Plan Reviewers NaMe �� N, � (} G 1 Date <br /> r <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 PERFORM WOR FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." //��,�-�� \ r� ( <br /> Applicants Signature Title CW SV'Coj Date k-44 l ki <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 <br /> signature <br /> and date below. <br /> E PHONE <br /> NAME E � - GCAJ c <br /> ADDRESS <br /> SIGNATUR <br /> EFI230038(revised 12/31107) <br /> 1 <br />