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ENVIRONMATAL HEALTH DEARTMENT <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 />I" <br />❑TANK RFTROFIT IPIPINf, PFDA1D/DCTDnCIT F-1—, F-]--. <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # y V v`✓ v <br />C <br />Facility Name M !aa 1P 1�l o SSc <br />Phone # ,q c 5 <br />Address L4 14 LA -A` V\-, O <br />T <br />Cross Street <br />Y <br />Owner/Operator {n1 12A (AC, V) c --s <br />Phone # �4 zv� i S'-7 5 <br />0 <br />o <br />Contractor Name (� c. s L L—`T G -C <br />Phone # <br />NContractor <br />T <br />Address � � � t, � � <br />CA Lic # Class <br />RInsurer <br />A <br />V--), L>'VA� C11 <br />Work Comp # <br />TICC <br />T <br />Technician's Certification Number <br />Expiration Date <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />❑Approved 19 -Approved with conditions ❑Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name�/��'�j/� g <br />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 <br />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 />THATIN THE PERFORMA E HE WORK FOR HICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signal a Title Data <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 <br />�fff the billing by signature and date below. �7 <br />NAME /" f _ "Z c ok- t o TITLE C PHONE # 3 / S <br />w� %LI 4-7 <br />ADDRESS <br />SIGNA <br />EH230038 (revised 12/31/07) <br />S C(I -2 5)-C <br />1 <br />