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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN 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 TYPEBELOW. <br /> 'AGK RETROFIT !PIPING REPAIR/RETROFIT _➢UDC REPAIRIRETROFIT <br /> F EPA Site# 0 Project Contact&Telephone# <br /> A <br /> D Facility Name , prt hone# _ 16 <br /> � Address 12 6 lest •rr <br /> T Cross Street arLiG <br /> Y Owner/Operator kc, I Phone# _3M 3 <br /> -71 <br /> o Contractor Name % Phone# 530_ 2.. <br /> T Contractor Address tJ I f CA Lic# 7 Class <br /> R <br /> A Insurer ' P r,SQ IuA Work Comp# 03- 0600 3 <br /> C <br /> T ICC Technician's Certification Number Expiration Date <br /> R ICC Installer's Certification Number s,�S 2 3� -U ( Expiration Date 9-4-07 <br /> -07 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> -I 3 Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P DApproved Approved with conditions ElDisapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name � , s , Date_ j �2, 6 <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 AGENTS 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: "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> 4 <br /> Applicants Signature <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 VCC&C < ��_LfPmor 1TITLEb iU%4VN kAmtniiPIHONE# 914-300714 <br /> ADDRESS I ` �— <br /> SIGNATURE! I <br /> EH230038(revised 8/8/06) <br /> 1 <br />