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04/09/2008 14: 23 FAX 17074466192 TAPW-TEK 001;,'004 <br /> RE-061v L,- Lj <br /> ENVIRONMENTAL HEALTH DEPARTM0f4w'92008 <br /> SAN JrOAQUIN COUNTY SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> 304 East Weber Avenue,Third Floor, Stockton, California 9520�1EALTH DEPARTMENT <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 ✓ <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERNIIT EXPIRES 00 DAYS FROM THE APFROVA.DATE. INDICATE PERN"T TYPE BELOW: <br /> ❑TANK RETROFIT PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name 2 C4 re Phone 0 O _ <br /> IL Address <br /> Cross Street <br /> T <br /> Y Owner/Operator Phone# S <br /> oContractor Name _ Phone# <br /> T Contractor Address G` CA Lic# Q .3Class <br /> R <br /> A Insurer •9S�$T Work Comp# <br /> _ <br /> T ICC Technlclan's Certificatlon Number 5A 4VI96 Explratlon Date S <br /> 0 <br /> A ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T .91 Vra a.0 cBOO <br /> A <br /> N <br /> K <br /> I <br /> P _/Approved gAlplprovcd with conditions :Disapproved <br /> L (See Attachment Wlth Conditions) <br /> N Plan Reviewers Name W�.w��.✓M tj Date ��/� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JCAGUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUI,N COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR L,CEiNSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I C=RTIFY THAT IN <br /> THE PERFORMANCE OF THE WORX FOR WHICH THIS PERMIT IS ISSUED,I SHA'.L 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 SIONATURE CERTIFIES THE FOLLOWING: "I CFRTiFY <br /> THAT,N THE PERFORMANCE OF THEW RK FCR WHICH THIS PERMIT IS ISSU:O,I SHALL EMPLOY PERSONS SUBJEC`TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ` • <br /> ADpllca�ts S noW�e � T'Hetic Dace <br /> BILLING INIJ XT10t: <br /> Indicate the rasponslble party to be billed For additional EHD staff time expended boyo d permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the parte must acknowledge this <br /> responslbillty for the bllling by signature and date below. <br /> NAME TITLE � PHQNF9 <br /> ADDRESS <br /> �ftl `�� _ ���h,�C �LS�2 <br /> SIGNATURE <br /> EH230038(revised 6/8/06) <br /> i <br />