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e <br /> ENVIRONMM <br /> AL <br /> ■ HEALTH <br /> SAN JAUIN 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 DAYSFROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT Y PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# ,Z -? 7 �, <br /> � Facility Name Q C t _ r Phone# (2090146c. -1421- <br /> 1 <br /> ZO 14 -! <br /> � Address e. <br /> I Cross Street <br /> T r nc <br /> Y Owner/Operator + kto 1c Phone# Z ) Z <br /> o Contractor Name 14MC — Ander-so Ander-son 1Phone# y 140- 7 <br /> N Contractor Address CA Lic# 4 7?! Class <br /> T <br /> R <br /> A Insurer W Work Comp# 110165,06 <br /> TICC Technician's Certification Number 7 Expiration Date (,-/Z-/l <br /> RICC Installer's Certification Number 5LSZq Z I Expiration Date ' O -07 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved %Aachment <br /> pproved with conditions ❑Disapproved <br /> L (See 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." a <br /> ApplicantsS ature Title1LG11 Date 11LZ6,166 <br /> BILLING INFORMATION: <br /> I dicate a responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the y designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> onsibility for the billing by signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />