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ENVIRONMVNTAL HEALTH DE RTMENT <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 /> UTANK RETROFIT UPIPING REPAfR/RErROFrr UUDC REPAIR/RETROFrr START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# &X j 3&7,4.OM <br /> A <br /> C Facility Name 5� +� SWEAKEFS O S G .r 37'>:C Phone#(24gil <br /> Address <br /> L "'70G10 Msz4tiALt_ GaN1s'S'$I�.V <br /> I Cross Street <br /> T <br /> Y Owner/Operator a,i1�.) C�9Phone# j <br /> C <br /> Contractor Name $AG a r~N �� S 3 7— <br /> Phone# Za - <br /> T Contractor Address 23`7v 1Y�t4 ter, g M— CA Lic# ?74ep2 Class 6 021$34 1D40 <br /> R IF <br /> Insurer Work Com <br /> A tri Yr�nw�o C c� p#w f,4 00q.5 jq <br /> T ICC Technician's Certification Number Expiration Date VI <br /> /t I �}'t67.B"' f � ��! 19 12,0 i G <br /> Cnstaer's Certification Number ration Date <br /> R ICC IllCifiEdi q�213�- 4 � O'713►/.z®to <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P HApprove J with conditions UDisapproved <br /> L (Se Attachment With Conditions) <br /> A Vz,� <br /> N Plan Reviewers Nameiw�jDate <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTEIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE CE THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" w <br /> Applicants Sigrotur Title Date 4 J- <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME YSqn6fAnWR4_SV_S. M-IL TITLE 6fA, —PHONE 1t(24:91\36�'�By[/ <br /> ADDRESS �c.37® iN►+A�G3,�O � �U-E.i Gtr („. ipZ + (, Q$ t7 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />