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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br /> ❑TANK RETROFIT XPINGREPAIPJRECROFIT L_ALnUDC REPAIRIRETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name '17—6 ' r/7XL. Phone# <br /> Address <br /> TCross Street ...s <br /> Y Owner/Operator `% �,ti/. ,[ ?/��L Phone# <br /> C <br /> Contractor Name �C'/ �/./e, Thane <br /> o GC -wiE K' <br /> N Contractor Address �,0 0%Ad�/D CI#C , L/i.4i CA Lic# '�7r; y006P� Class,f ��� D3y yq, <br /> AInsurer Work Comp#/ "4'- Or <br /> T <br /> T ICC Technician's Certification Number Expiration Date <br /> R ICC Installer's Certification Number Expiration Date ollordlrr� <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑APer ved pproved with conditions ❑Disapproved <br /> L {Se Atta ment 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 AGENTS 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." <br /> Applicants Signature Title Date <br /> BILLING INFORMATION: <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. / �y <br /> NAME fez& ,e�4'zFY TITLE ( 'COI/C?/�IG //,4i/X0rPH0NE# <br /> ADDRESS 7O �r�/O C/ r� Ot7/ �,�•�yO <br /> SIGNATURE <br /> EH23W38(revised 12/31/07) <br /> 1 <br />