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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, 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 �iUDC REPAIR/RETROFIT <br />F EPA Site # Project Contact &Telephone # I v1 Z <br />A , Phone # <br />C Facility Name 11 1 , j> \p <br />I Address W2 <br />L <br />T Cross Street tic. <br />Phone # <br />Y Owner/Operator ti fit' l� <br />C Contractor Name +� <br />Phone # <br />o � <br />N Contractor Address 4 1 (,fir �, (. LCtj�n� � � CA Lic # ZC1-�� Class <br />T r� <br />R <br />Insurer �tL WCy1A't Work Comp # 2-(;��C��P <br />c ICC Technician's Certific tion Number OtP� j Expiration Date <br />T <br />RICC Installer's Certification Number _ (vL� Expiration Date <br />Tank ID # <br />T <br />A 2 <br />N <br />K <br />P i!Approved <br />L <br />A <br />N Plan Reviewers Name <br />Chemicals Stored Date UST Installed <br />Tank Size 1 Currently/Previously <br />Oil <br />t ckk� <br />90proved with conditions ❑Disapproved <br />Attachment With Conditions) <br />Z/ <br />APPLICANT MUST PERFORM ALL WORK. CCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL H ALTH 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 P RFO ANCE F THE WO FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA 6 ^ A t1. / <br />(� n I (� /1 e V' , I ' /l f1 <br />BILLIN INl- ORMATION: <br />indicate the responsible party to be 'lied or additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is differ than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the <br />(billing <br />(bby signature and date below. �{.( <br />V 111 «kph IQ 1 JU ti�� T I T L J �( '� t i l �l�yI G � PHONE <br />ADDRE <br />SIGNA <br />EH230038 (revised 8!3!07) U <br />C(OPY <br />1 <br />