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.ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />TeleP hone: (20p).468-3120 Fax:(209)..468-3433 <br />x <br />APPLICATION FOR UNDERGROUND STORAGE TANKR TROFIT OR PIPING REPAIRPERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />nn <br />tJTANK RETROFIT . OPIPING REPAIR/RETROFIT ©UDC REPAIRIRETROFIT <br />F.: EPA Site #= : Prnject Contact Telephone # �C <br />A.` <br />C Facility Name Phoneif* <br />L <br />Address ' <br />Cross Street . <br />T _ <br />Owne-doperator ` — Phone <br />Contractor Name <br />o: , Phone:# -i` ... . <br />N Contractor Address . , <br />T tJEC1�S3Y1' CA -12 <br />Lic # • / /f_ Class t <br />T (!1 V <br />A Insurer . Work Comp # _ <br />C. <br />T. ICC Technician's Certification, Number Expiration Date <br />R ICC Installet's Certification Nlnnber Expiration Date . <br />Tank ID # Tank Size Chemicals Sfon;d pate UST Installed <br />Curren'00reviously . <br />TN. <br />. <br />H#.y <br />P DApproved w rovel.with Conditions Disapproved <br />L , <br />(See nt With Conditions) <br />A: I <br />N Plan Reviewers Name" <br />Date <br />APPLICANT MUST. PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUINTY ORDINANCES STATE LAWS AND RULES AND REGULATIONS OF,SAN <br />JOAQUIN COUNTY, EkViR uRsk L HEALTH"DEPARTMENT. OWNER OR LICENSED A6ENTS.SIGNATURE- OERTIFIE&;THE FOLLOWING. .*I CERTIFY THAT IN <br />THE.PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT.EMI�L-OY ANY PERSON 0t SUCH-A MANNERAS-TO BECOME sUBJECTTO <br />WOWM'S -COO ENSATJON.LAWS OF:CAUFORNIA.I CONTRACTORS.H;f QNG OR SLBCONTRA&iNP*'. ari4ATURE .CER-nF1ES THE FOLLOWING: `M CERTIFY <br />7'FIAT_.IN,TjiE PE WRMANCE OF THE. WORK FOR WHICH THIS PERMIT IS ISSUED; I SHALL EMPLOY PERSONS SUB;IEGf TO wdFtKER'S CCN�APEWSAi1ONLA1NS <br />OF CALIFORNIA.":: . <br />le <br />'II'II�II <br />` BI!_ GINFORAAATION; <br />Indi>±ate;the responsible party-to be_Isilled for addltronal;kiD statftlrxleeXpended beyond %permit pagriient c:ovirage per tatik if. <br />+e P �! 9 IDvr� s dlffe ei�i`ifaar�i-the-pnrrrjfi�aP li nt�=—ProPerr owner e - mns a o <br />- . p ge this <br />responsbllltyforthe billing bysignature and"date below.. <br />NAME [L'�`"�_T1TLE Fll 0 L�d11r t �C J PHONE #QQ <br />SIGNATURE, t <br />EH23oo38 (revised WNW) <br />