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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 RU-DC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> APhone# <br /> G Facility Name r�,R 2( I C...Ah - 7(0 <br /> I Address <br /> L r <br /> TCross Street yS <br /> Y Owner/Operator tG&('PL irZ__ Phone# 3o — 97 37 337 <br /> C Contractor Name _ Phone# 7u�_�Qf <br /> o tr� � (k �i�t1 C� <br /> N Contractor Address nl�e A CA Lic# 3 k9 Class ra,c i ID,/ <br /> T 12�6Lv�Ft+.. i !tw <br /> RInsurer S�S�r4+� l o U� L.. Work Comp# 000 <br /> TICC Technician's Certification Number P-j Expiration Date j!I <br /> o <br /> R ICC Installer's Certification Number Expiration 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 proved with conditions []Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL V0fK 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: "1 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." ` /�/ . A-eA IZ4 <br /> Applicants Signature ✓� i. _ Date <br /> BILLING INF 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 for the billing by signature and date below. <br /> NAME f)—(- V, TITTLE (a,.,l ����F'���c+✓_ PHONE# 113 <br /> ADDRESS L Sci.) O�J� �n_r t mac. 1,f <br /> SIGNATURE <br /> EH230038(revised 8/8106) <br /> i <br />