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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 TYPE BELOW: <br /> TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name C-,CLS Q O Phone# 202 - gam-p 33�L <br /> I Address <br /> L l�: CS�YY�t+ 2 A�l-e <br /> ICross Street <br /> T <br /> Y Owner/Operator ,7 p y`G N u-r- Phone# S g_,7 0 3 l <br /> C Contractor Name �� , e P�trG�(�, S L��CALic <br /> Phone#���- y S- S$ <br /> T Contractor Address Sa J B r a r c11 r� n 5'f'i $3 7 0LP Class <br /> R <br /> A Insurer 13C [-h bit Y"o r�rti��� Work Comp# f�- <br /> I - <br /> T ICC Technician's Certification Number ESQ yS l u� Expiration Date 9la-.7 A,q <br /> R ICC Installer's Certification Number �j Expiration Date 9 �9 JD�( <br /> � � C`i51- �LT p' <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P []Approved L' Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name 6ANVl�NT1r� 1� (N`� Dates 17 1 U� <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 PER1`013tMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" p <br /> Applicants Signature )"qk- Title Date '� I I I o <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 thiefbilling b�singna�ture1and <br /> �date below. <br /> NAME � 1 l J(IJ 1 I�Y UIJ�f TITLE MrU rkkA PHONE# ��"► - g�����J� `' <br /> Q r <br /> ADDRESS L—DJJI vel <br /> SIGNATURE �ya fir,\ r� 5-- <br /> EH230038(revised 8/8/06) <br /> 1 <br />