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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 OUDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# (Cj4 pg L (A)AL ro A( t714 •3 4 <br /> � Facility'Name (Quilt- S-ro fp *-/3z-- Phone# <br /> � Address S•s 5- <br /> Cross <br /> Cross Street <br /> T <br /> Y Owner/Operator Q v(V- S TO IP VtA A-R IL Vr-S C. Phone# S 1 0 <br /> C Contractor Name p,L T-0 r4 FiK C.t XL IS C 2/u111 C - Phone# b 3 1 <br /> o <br /> T Contractor Address 13 0 0 2 (AJ• S A-C>!'� J- Ct t CA Lic# (� 11. Z.3 F Class Q 6 N�Z <br /> A Insurer 5-l-pr-1-�, F ►J D Work Comp# <br /> c ICC Technician's Certification Number S e,%-. A-T-T fHGek G� Expiration Date <br /> T <br /> RICC Installer's Certification Number �� Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T p <br /> A ® Z �O p0 — (; A� <br /> K ® 3 9-, 000 Ctl <br /> P ElApproved Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name OIL <br /> 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 LAW OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMAN E OF HE WORK FOR WHI H THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Date <br /> Applicants Signature Title �n"'�t ���` <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 /Kby signature and date below. G <br /> NAME W �.�Q�/S f �1 ► /�'1-�K`C. TITLE �8.t'� �CJ(•Ot� PHONE# %�6 3 ' <br /> Ct <br /> ADDRESS \ p ' !� i!O / S'6 <br /> SIGNATURE <br /> Vk <br /> EH230038(revised 8/8/06) <br /> 1 <br />