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02/20/2001 WED 15:24 FAX 2094683433 Sic CHID ---• Stockton Sery Sta Eq Cc 4003/Ovo <br />r <br />SAN JOAQUIN COUNTY <br />600 East Main Strect, Stockton, California 95202 <br />'I dephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PER WT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW <br />t.t 1'T I IPI `.G �.E!',=�f+'PET( Of IT (UDC REPk RJFtETRO�--1T ' rD STARTIEVR UPGRADE <br />r _'F, Sate r Pro c ct Conr�ct & Telephone # ' % ?e <br />-- ------- - _- <br />I Facoily Nal e . Phone # <br />7 Cress Streetj_-_� <br />(Y Phone # <br />CoactorName - -- - Phone #a® <br />o------ -. _ _ <br />Contractor Address 0 0 '- '" CA Lic # , Class669 <br />rsure• Work Comp # QQ <br />I R I -G <br />T !CC-I'ecnnrc an's Certification Number Expiration Date <br />R ICC nista tor's Certification Numbert ® Expiration Date <br />------------------._..__._._ .111_`®, -._._..____----.._..--- <br />I Chemicals Stored <br />Tank ID # I Tank Size Date UST Installed <br />Currently/Previously <br />TA t -LA AMA J"L <br />T------ --' — —. -- <br />A <br />i <br />i <br />I i <br />f _ <br />P (Approved Approved with Conditions �-]Disapproved <br />L (Se achment With Conditions) <br />A <br />rI Plan Reviewars Nam <br />I <br />APPLI;,ANT'Au3T PERFORM ALL WORK W ACCORDANCE WITH SAN JOAUUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN j <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br />THE PERFORMANCE OF THE RK FOR WHICH THIS PERMIT IS ISSUED, i SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S Cf <br />i� A i6N L W�iSF-CALIFORNIA,;;CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br />THAT IN THE PE FyR1J{ANCE 0' THE WORK FOR WHII;}TTI;IS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA. <br />e r <br />AOpka, U1_ <br />BILLING INF RMATION: <br />Indicate the responsible party to be billed for additional EMD staff time expended beyond permit payment coverage per tank. If <br />the party designated belcw is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />respons,bil;ty for Me hiding by Signature and date below. <br />r -a - i <br />NAME1-�,<<a. (...-'.,'s-� �-- _._ ._..Trrt t_ _.._...---...___PHONE # �• t _�.;�� —. <br />ADDRESS <br />SIGNATURE-- -\- -- — - .. ---- -- - <br />EH230038 frev;sen 12!31;0/) <br />I <br />0 <br />