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May, 29. 2007 9. VSAM � � • No. 0491 P. 1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY" <br /> 304 East Weber Avenue,Third Floor,Stockton, California 952202 <br /> Telephone: (209)4683420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT R PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE, INDICATE P MIT TYPE BELOW. <br /> TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRMETROFIT <br /> F EPA Site# Project Contact&Teleph e# <br /> C FacilityName Phone# <br /> L Address wt , k NIM EI)� <br /> TCross Street <br /> Y Owner/Operator p _ <br /> C Contractor Name Phone# I , <br /> T Contractor Address ` -CA Lic# Class <br /> A Insurer�j\\\ Work Comp# <br /> TICG Technician's Certiflcation Number Expiration Date <br /> R ICC Installer's Certificatlon Number Expiration Date <br /> Tank Ib# - ank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> i . <br /> T <br /> A <br /> N <br /> K <br /> PppZoo <br /> $Approved with conditions ❑Disapproved <br /> L (See AttachmenE With Conditions) <br /> A <br /> N Plan Reviewer ame RV14 Datea �ITl(o� <br /> APPLICANT MUST PERFORML WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRON ENTAL 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 COMPENSATIQN 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." Ci <br /> ApplicantsSlgnalure ;' Tiller Dale <br /> BILLING INFORMATION: <br /> Indicate the responslble 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 /> responsibioy for the billing by signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> 5H230038(revised 8/8/00) <br /> 1 <br />