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r <br /> AN TAL JWRTMENT <br /> AH DE <br /> Q C T <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 <br /> APPLICATION FOR.LINDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> DANK RETROFIT []PIPING REPAIR/RETROFIT OUDC REPAIR/RETROFrr <br /> IF EPA Site# Project Contact&Telephone# <br /> C Facility NamePhone - <br /> L Address `U <br /> Cross-Street <br /> T` _ <br /> Y Owner/Operator Phone# . <br /> o , <br /> Contractor dame` '` ,. Phone.# q. <br /> N. Contractor Address .ST(1�1CCY1' CA lac#: (� <br /> T . <br /> R. <br /> A Insurer' Work'Comp <br /> 5 <br /> T ICC Technician's Certification Number Expiration Date <br /> R l <br /> ICC Installers Certification Number <br /> R Expiration:Date <br /> Chemicals Stored <br /> Tank ID# Tank.Size Date UST Installed-: <br /> Currently/Previously <br /> A <br /> N, - . <br /> K <br /> P... ElApproved prov h-conditions ElDisapproved - <br /> L A nt tions) <br /> A . <br /> N _ <br /> Plan Reviewers Name Date <br /> --=_�P-P-i-lC,4N7�r1UaT�ERF-ORIt�-�-1AIflRK-1N=A1aG®RDANGE-WWR`-M-S#1t�=JQAQk11N��F7N�Y=QRTiiNANEES�-Ti1"F�=I�I�YS-�1J(JrRUC-E5�1D73EGDDt�1TI�5hTS� - <br /> .MAMIFI,COLJim"iTNVIRONMENTAL HEALTH DEP ARTMENT.OWNER O[2.LIGENSl31 AG�NTS.sidWuRE cERTIFiEs:THE FOLLOWING:."1 CERTIFY THAT IN <br /> THE PERI ORMANCE OF T'HE WORK FOR,WHICH THIS PERMIT IS ISSURD.I SHALL NOT-EiIAPL-oy ANY PERSON JWSUCH A MANNERAS TO:BECOME:SU13JECTTO <br /> _. <br /> WOWER5:C0[y'ENSATION.LAWS OF_CALIFORNIA.". CONTRACTOR'S_HIRING OR SUBCONTRACTING SIGKATURE.CERTIFIES THE FOLLOWING;,'1-CERTIFY, <br /> THAT IN:TM-PERFORMANCE OFTI.IE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED i SHALL EMPCOI'•F ERSONS'SU6IECTTO`WORKERS COMPEt;ISATtON.T.AINS <br /> OFTCAL IFORNIA <br /> y�Inn,, <br /> Appr�cants Signature I�u t i► ��13�� title 4 Date <br /> BILLING INFORMATION: <br /> FORMATION; <br /> ..,lndloate the responslb(eparty.4o be billed for_add�lonal EHQ staffjj expended:beYc�nd perrrtlt:payrnent coverage_per tank.-.If <br /> itis party do-gneted :b lew dif i n tha e:The permit.a"llcant�..e _ .. ._ <br /> pp g PpertY o;rrner,:the party must acknowledge this . <br /> espQnsiblllty fnrxhebillingby:signatcrre and'date:below... <br /> - - <br /> t M--- <br /> PHONE <br /> T l ��1t�--- <br /> - - ..: .. <br /> - <br /> ADDRES <br /> .SIGNATURE . "I_ �) r i�A YL�I <br /> EH230036(revised 8/8!.06) _ <br />