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0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> q� THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> L�.TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone#jfl(C v A tt t k/A( i W q(6 -3;)• 11 r <br /> � <br /> Facility Name D R E W p�t� Phone# 2 0 cl Cj�(( - 8 `(3 <br /> L <br /> Address Z q 9�( E _ F5(L E A ems" S T - $ To C l_T_" Q $- 2 0 E__ <br /> Cross Street <br /> T <br /> Y Owner/Operator t C W A K i b y bL►,►t (�V L 2. Phone# <br /> o Contractor Name U f IN1 T-O h1. (' _ Phone# q 3 <br /> r 6 - 3 } <br /> N Contractor Address B p X /0 L 1' (�, S A4," 9 S'6 4 i CA Lic# (o (}L 3 Y Class A , (�,, k�a Z <br /> T <br /> A Insurer -i-A-T E F v Work Comp# (3 po%{ 9 Z -0 <br /> T ICC Technician's Certification Number s j✓v� A-T T A-C lk Expiration Date <br /> Q <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T 0 1 / 5 000 "} — C 11—soG 'eq IL Z00f <br /> N p Z. / 0 000 / — C "C <br /> . /�L ZOOS <br /> K <br /> P ❑Ap roved pproved wit s ❑Disapproved <br /> L (Se Attachment With C <br /> A v� <br /> N Plan Reviewers Name <br /> WW — —4- <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,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS F CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF <br /> E WORK FOR WHIC THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title Q4L:K (2- 4-t� Date 0 r� /0 <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 /> responsibilit for the billing by signature and date below. / <br /> NAME l C M'rt/L (,(/A-/✓% TITLE C_&9--L;�_11 kM-P—A PHHONE# <br /> ADDRESS U 0 /O Z `i" ' S T ( r 6 R <br /> SIGNATURE <br /> V - V C_�-Vv <br /> EH230038(revised /07) <br /> 1 <br />