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May. 29, 2007 9:55AM No, 0491 P. 1 <br /> • i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY" <br /> 304 East Weber Avenue,Third Floor,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 90 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE eELOW. <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name C.�?( V t Phone# <br /> I Address w1 >,*V1 <br /> L <br /> TCross Street <br /> Y Owner/Operator \� ,\I Pho # (gyp _ ` <br /> C <br /> Contractor Name ,`hone# <br /> T Contractor Address CA Lie Class <br /> A Insurert�j\\� +cJ� e, . Work Comp# <br /> T ICC Technician's Certification Number j\\ Expiration Date (�- <br /> o ICC Installer's Certification Number Expiration Date <br /> R <br /> Tank Ib# Tank Siz Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K a <br /> P ❑Approved $Approved with conditions ❑disapproved <br /> L (See Attachment With Conditions) <br /> A (( <br /> N Plan Reviewers Name_ iw lima Date q III W <br /> APPLICANT MUST PERFORM ALL RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONME AL HEALTH DEPARTMENT,OWNER OR LICENSED AGENT'S SIGNATURP CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE W, RK 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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA," <br /> ApplicahN Slgnsture Tills � � Date <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 /> responsibility for the billing by Signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> — <br /> 5H230038(revised 8/8/06) <br /> 1 <br />