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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQMN 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 BELOW <br /> ANK RETROFIT UPIPING REPAMETROIFIT UUDC REPAIR/RETROAT <br /> F EPA Site# Project Co/n�tact&Telephone# <br /> C Facility Name )�,( .f (' (//�C�Y!` Phone <br /> L Address 1 ' r 1 <br /> I Cross Street <br /> Y Owner/Operator ' Phone# ' (_Mf (�2 <br /> C Contractor Nam Phone# <br /> 0 <br /> N <br /> T Contra dress ' CA Uc# j(O Cta <br /> AInsurer I , _ Work Comp# �. 1 �6 <br /> TICC Technician's Certification Number !` '95 -u! Expiration Oa <br /> OICC Installer's Certification Number Expiration Date <br /> R <br /> Tank ID# Tank Size Chemicals Stared Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P [-Approved proved with conditions UDisapproved <br /> L (See Attachment With Conditions) <br /> A r/I� <br /> N Plan Reviewers Name ��Ii lUl Date U 0 <br /> APPUCANT MUST PERFORM ALL WORK IN ACCORDANCE WITH,SAN JOAW N C UN rY ORDINANCES.STATE LAWS AM RULES AICD REGULAT"I S OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR uaNsED AGaas SIGNATURE CERTIFIES THE FOLLOW,ANG: "1 CERTIFY T14AT IN <br /> THE PERFORMANCE OF THE VNORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPDISATION LAWS OF CALIFORNIA." CONTRACTORS HIRING OR SUS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFOR OF THE WORK FC R WHICH THIS PERMIT IS MM,1 SHALL EMPLO Y PERJE <br /> SONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' �f� <br /> ApplicaKsSignatue �)h �l �L Tttfe <br /> BILLING INFORMATION.- <br /> Indicate <br /> NFORMATION: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 /> responsLb iii for the billing by signatyre(and date below. ` J� <br /> NAME <br /> l (/,�j LJ TITLE\'�'I� HONE#114, 17Y 41 <br /> ADDRESS <br /> 1 � <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />