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0 <br /> 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 BELONr. <br /> UTANK RETROFIT UPiPiNG REPNR/RmonT LJuDc REPAtR/RETROFIT <br /> F EPA Site# L ProjectCanha4 Telephone# rI,-, 0-7 106/-lid3 7 <br /> C Facility Name .bnOgD Phil�l s S Phone#0765 - q7$- /S3zt <br /> L Address j tf(Pq 4C &MMQ'r C'k CA3 saga <br /> I Cross Street <br /> T <br /> Y owner/Operator •"O c c h /(�• S Q I h Phone# ,2�9- S! - <br /> Co Contractor Name �i G /t B�YcLt cr+ :L h(i Phone#,o?c 9- 7 4 l- 6 331 <br /> T Contrac4�r Address s'� m , CA Uc# Class C /10 !yR <br /> R Insurer, r to r� 5 work Comp# SO/7W <br /> T <br /> T ICC Tectmician's Certification Number Expiration Data <br /> O <br /> R ICC Installer's Certification Number Expiration Date <br /> ed <br /> Tank ID# Tank Size <br /> Chemicals vusl Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P UApproved ved with conditions UDisappraved <br /> L ( drment With Conditions) <br /> A <br /> N Plan Reviewers Narrle Date 2 7 <br /> APPLiCRO MUST PERFORM.Jil3.lkOEilC @I.ACCORDANr-F-.YFlITriSAN JGftp&lW=ZETY.QRPNARXS_,STATE LAYYF:At H�r S.AIsD_REG[A�Cr-PPM OF SAN <br /> .IOAC IM COL NTY,EW ROWENTAL HEALTH DEPARTMENT.OWNER OR LICBMED AGEMPS SIGNATLIRE CERTIFIES THE FCkLO AC: '1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WOW FOR Y"CH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MA44B2 ASTO BECOME SUBJECT TO <br /> WORKER'S COMPS•s=)N LAWS OF CALIFORNIA.:- coNTRAcTOR s mw OR sjaoouTRAcnNG srNATURE CE ayiEs THE POLLOYw jG: h CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORE(FOR VNiCH TM PERMIT IS fSSUE),I SHALL EMPLOY PERSONS SUS.ECT TO ViORKERS COMPRMTION LAMt5 <br /> OF CALIFORNIA' <br /> App <br /> licarts Tdfe Vtc�c Coordlrra�vYD /I -tel-b'/ <br /> BIWNG 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 admowledge this <br /> responsibility for the billing by signature and date below- <br /> NAME <br /> /_ �, <br /> NAME '�liJ.f.� l�T.Lly TiTLE SCr ltc a Goorc�rna�OY'PHONE# <br /> c P l / <br /> ADDRESSy 3S Oil RA C m V r �e-kAM f orh S.-®s <br /> SIGNATURE <br /> EHt230038(revised affi i) <br /> 1 <br />