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L <br /> TM <br /> ENVIRONMENTAL HEALTH DEPAR �,,N <br /> Tt) <br /> - L <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton, California 95202 <br /> P t__RI R V 1 CE S <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 /> XTANK RETROFIT I_PIPING REPAIR/RETROFIT I.JUDC REPAIR/RETROFIT ]COLD START/EVR UPGRADE <br /> F EPA Site# _TProject Contact&Telephone# <br /> A <br /> C Facility Name 010(Moyl —usti 'a Phone# <br /> Address '±> 55 <br /> L IAAo <br /> T Cross Street <br /> Y Owner/Operator Cka L)rw Phone# <br /> Phone# <br /> C Contractor (0 <br /> 0 2_0 <br /> N <br /> T Contractor Address LL to Ilk) jc&4U,` W',, Q &4, -5-1-.3 8 1 CA Lic# Class <br /> L4 <br /> R Work Comp# <br /> A InsurerF/-A^k �441 &7VnP&-n4 L/?,�C(Qj <br /> C _'_7 90 Expiration Date 14,01�0 <br /> T ICC Technician's Certification Number 1<40 _Z <br /> 0 <br /> R ICC Installer's Certification Number Expiration Date <br /> Chemicals Stored <br /> Tank ID# Tank Size Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> IN <br /> K <br /> p I lApproved >1414proved with conditions .]Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name_4:� � Date— <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: "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 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> ApplicantsDate Signaturel����� <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 TITLE —PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br />