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ENVIRONMENTAL HEALTH DEPARTiv, SED <br /> SAN JOAQUIN COUNTY ocT _ ���� <br /> 600 East Main Street, Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-34 3 tiNVIRO°q'i IVT HEALTH <br /> PERNII�ISERVVCES <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 /> JTANK RETROFIT FIPIPING REPAIRIRETROFIT CJUDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A _ <br /> C Facility Name ��CO P, Dba f3 O P one# <br /> Address CA- q,5_3 <br /> -- - <br /> T Cross Street -- <br /> Owner/Operator Phone# <br /> Q Contractor Name �/�6�G Phone# <br /> T Contractor Address -7 CA Lic# 11 3 l&D Class <br /> CInsurerf--rAot16Cjt 4-,,,L ¢ Mirk 3(IZ_5gv77 <br /> T ICC Technician's Certification Number J UQ E)piration Date S— D <br /> RICC Installer's Certification Number <br /> E piration 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 1Ypproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A II� � <br /> N ,^Plan Reviewers Name l.Q /" , Date_ tot a 6q1 <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." <br /> Applicants Signature Title Dat@ 'T Z <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 />