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10/09/2006 15:30 7074466192 TANK-TEKPAGE 01 <br />1p <br />ENVIRONMENT.. L .. .. >L....I. . <br />30� <br />APPLICATION FOR 1 <br />TH <br />❑TANK RETROFIT <br />i&PIPING REPAIRIRETROFIT <br />202 <br />INC REPAIR PERMIT <br />DW: <br />I IUDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone <br />CFacility <br />Name <br />Phone # -"7 <br />'Address <br />L <br />I <br />Cross Street ` <br />T <br />Y <br />Ownertoperator <br />Phone #q1 - 311- ;25-K-) <br />o <br />Contractor Name . iPhone <br />#��-� f j <br />T <br />Contractor AddressanID AkkMTj Lic# Class <br />AInsurer <br />Work Camp # <br />C <br />T <br />ICC Technician's Certification Number A <br />Expiration Date <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />F�rv� <br />QM <br />A <br />N <br />K <br />P <br />❑Approved LJApproved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name G� ' ( J�� ° Date --/v Ic e <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- '7 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 rOR WHICH 110 PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />LYAML <br />Applicants Sl nsiu TltleL&L Date <br />BILLING INFORMATIQN;�_J <br />Indicate the responsible party to be billed for additional >*HD 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,billing by signature and date below. <br />NAM Itoja t/ i% rirLS,tCe PHdNE # i0"�C�-F' <br />ADDRESSUL� l F i 1.L1 a _1 �-' T t Y l �i><�o U l'S..LUt <br />EM230038 (revised 818108) <br />n <br />