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� r <br /> ENVIRONMENTAL HEALTH DEPARTM Irq <br /> SAN JOAQUIN COUNTY �E� <br /> 600 Fast Main Street, Stockton, California 95202 SEP I jG8 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 F���� 11, i r t,4,•.r T <br /> H <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING RE-PAIR PER11 u <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> I (TANK RETROFIT UPPING REPAIR/RETROFIT LIUDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A Facility Name A O Phone# <br /> IAddress Ca <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> oContractor Name Phone# <br /> N Contractor Address `� Q Q PN CA Lic# Class <br /> T —1 <br /> R Insurer RA � S At Comp# Z�0�02 I <br /> A <br /> T ICC Technician's Certification Number Expiration Date <br /> T <br /> QICC Installer's Certification Number Expiration Date <br /> R <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P I_JApproved pproved with conditions LJDisapproved <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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." / — ^ �Applicants Signature! Title yr r \�( W V Ar v Ze-, <br /> V <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 signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/3/07) <br /> 1 <br />