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0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQWN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 f� <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW. <br /> LITANK RETROFIT UPiPING REPAIRMETROFIT I ULIDC REPAIR/RETROFIT <br /> F EPA Site# Project CDntact&Telephone# 'Zf r <br /> A <br /> C Facility Name Phone# - 3 <br /> IAddress 3 <br /> L GZlf <br /> ICross Street <br /> T <br /> Y Owner/Operator A lbVI 14v Phone# <br /> o Contractor N u �,�- 'l Phone# <br /> TContractor dream CA Uc# Class <br /> R Insurer Work Comp# }/ 8�)D <br /> A <br /> T ICC Technician's Certification Number VS 5-7 T` Expiration Data <br /> O <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P (JApproved Approved with conditions UDisappraved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date �'� I <br /> APPUC ANT MUST PERFORM ALL WORK.IN ACCORDANCE Wall SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND_REGULATIOr tS.OFF SAN <br /> JOAGXkN COUNTY,EwRoNmENTAL HEALTH OEPARTMENT.OWNER OR uaNsED AGENTS SIGNATURE CERTIFIES THE FOLLOVVNG "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHIG THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSALAWS OF CAUFORNIA" CONTRACTOR'S HIRING OR SUS SIGNATURE CERTIFIES THE FOLLOVANG: I CERTIFY <br /> THAT IN THE PERFORM OF THE WORK FOR WHICH THIS PERMIT IS ISSNE <br /> ,I SHALL EMPLOY PERSONS SUB. CT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Ili <br /> Applicards Sicp�attr. I Title 1Jl L <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 pa .designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> respon /�it-y for the billi by sig ature and date below. 4- W <br /> ' , / �' <br /> NAME TITL 1/i�rC.f 1 PHONE# <br /> ADDRESS L/�-�`3J N1 <br /> SIGNATURE <br /> EH230038(revised 818106) <br /> 1 <br />