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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 �L'PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A PtAL2 4( _ 4L)k_ _ // <br /> D Facility Name Ca Phone# 20vy zl'f 51� j-7 <br /> I <br /> L Address <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# JO5 --173-?337 <br /> C Contractor Named G �� c?'� S Phone# t�v �3r�-71J3 <br /> T Contractor Address Lo V 1 n h -(� _ <�J- CA Lic# 8 5/ Class 0 eU A�4Z <br /> RInsurer //11 <br /> A ass Vt►��I�C'� c_v. Work Comp# 3-3101)2 Q I&v <br /> cICC Technician's Certification Number <br /> T 00 144 _ (�'I Expiration Date —�2.Zeo <br /> R ICC Installer's Certification Number <br /> Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> N 'rk 2 ervu.tt�'1 <br /> K <br /> P ❑Approved ,Approved with conditions ❑Disapproved <br /> L S <br /> A See ment With Conditions) <br /> N Plan Reviewers Name <br /> Date 2 3 Xoa <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 P RMIT IS UED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." /� / I-e/L p � `1yam <br /> Applicants Signature_�Zw—( /i Title Gt �,,.c- Data <br /> BILLING IN RMATION: <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 four the <br /> nbilling <br /> ,/by signature and date below. <br /> NAME L TITLE h 0 J Q <br /> PHONE <br /> l l/ <br /> ADDRESS ()I)/r7r? AveAr7 fog-e — <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />