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0 <br />• <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 />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />I Vf , rnnioiooTonnT F�I❑lR REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />b, DbA <br />APhone <br />C <br />Facility Name (j <br /># %Z <br />IAddress <br />L <br />jqiA <br />TCross <br />Street <br />Y <br />Owner/Operator t ` <br />Phone #j� <br />oContractor <br />Name t �� r <br />Phone # %J. <br />T <br />Contractor Address `!Zl (�(jl L C�C1l� � � CA Lic # Z�'-;lt-j Class A <br />R <br />Insurer (,� L j�� Work Comp # ^ �yj(Q(p0 <br />TICC <br />Technician's Certific tion Number C) C5 <br />Expiration Date <br />o <br />R <br />ICC Installer's Certification Number �CJ� _ (�,( <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Date UST Installed <br />T <br />ICurrently/Previously <br />lI cxx� <br />C1 <br />A <br />Z <br />t1b <br />K <br />wo <br />ut <br />P <br />❑Approved Approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date Z Z1 V <br />APPLICANT MUST PERFORM ALL WORK I 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 PERFORM CE OF THE WORK FCR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." _ /�r}r�` r I} r vAI & J <br />,,.....,..,..,� �:,......,..,, / I` ,(,IYI A . („IIYYII(,'�iL TM. '(''/� 1 '([_ Jy1\[,,J{.'„V_ �� Date G <br />Indicate the responsible party to beIlled f r additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is diffe nt an the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing bysignatureand date below. <br />NAME ISC. u TITL nn <br />PHONE <br />S <br />EH230038 (revised 8/3/07) <br />C(OP <br />