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RRIVEDD <br /> ENVIRONMENTAL HEALTH DEPART MEWT1 2008 <br /> SAN JOAQUIN COUNTY ENVIRONMENT HEALTH <br /> 304 East Weber Avenue, Third Floor, Stockton, California 9520JERMIT/jERVICES <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 z �' <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PEW..41T EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT PIPING REPA!R/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name PI-one it .2o'?— p _4Pj!Z <br /> I <br /> L Address <br /> TCross Street <br /> Y Owner/Operator Phone# , S <br /> o Contractor Name _ Phone# 0 <br /> T Contractor Address Q' CA Lic# OS Class <br /> R Insurer Work Comp# <br /> A <br /> T ICC Technician's Certification Number 5 a 0 6 _ Expiration Date <br /> R <br /> ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P []Approved ❑Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <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 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 PERFORMANCE OF THE W RK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature = Title lb� Date <br /> BILLING IW WMXTIft <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyo d permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the part,- must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME ?Q.� g 5 n TITLEOLPHONE# 7�_ y� <br /> ADDRESS �n n� ffi'a _ 2A-�--gCo "I ��L'=�CA 9-S CLI rI <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br />