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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 (6 <br /> F EPA Site# Project Contact&Telephone# M I.C41 A,FL U/A LTOn( <br /> � Facility Name L Phone# <br /> I Address <br /> L � } oo Bnr LAS - <br /> I Cross Street A 0,\(M Ems, �( . <br /> T <br /> Y Owner/Operator A L 4 S t A K ( £ Phone# <br /> C Contractor Name A K ( [4 E-C:L tr u< r- Phone# <br /> 0 <br /> T Contractor Address B O (O Z S- (,O o �/S 6 q ( CA Lic# f Z 3 Fr Class A B N�¢Z <br /> RInsurer U j Work Comp# }1'3 00 0,0 z�0 6 <br /> T ICC Technician's Certification Number S E E A-TT A-C 4-� Expiration Date <br /> R ICC Installer's Certification Number �£ /�-t-'t Ar-C W" Expiration Date <br /> Chemicals Stored Date UST Installed <br /> Tank ID# Tank Size Currently/Previously <br /> T � ( ► S O 0 O .A-Q - is� <br /> A $' 0 O O p-S - of <br /> N <br /> K <br /> P ❑Approved &pproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name l�• N� Date 7.,`12-01 <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 LAVYS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE O THE WORK FOR HICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF`CALIFORNIA." <br /> Applicants Signature Title C k�12 A't t t h 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 /> responsibillitty�Ifor the billing by signature and date below. C� <br /> NAME Y 1/l r u",1- W A' TITLE 1Z AVCO h PHONE# 3 ) 3 <br /> —r <br /> ADDRESS Q D X l O Z S- "" ,tea C <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />