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ENVIRONMENTAL HEALTH ®EPARTM,9, �i� ; <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 RE1PA1R'PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT OPIPING REPAIR/RETROFIT UDC REPAIRMETROFIT OCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A q 6-15-11�6 <br /> , <br /> C Facility Name --4. Phone# 51b - X5-1- i3Sbv <br /> L Address <br /> TCross Street <br /> Y Owner/Operator f9 - �� � � Phone# S\O -LoS-1^ SS no <br /> C Contractor Name A ` Phone# o\ <br /> T Contractor Address �,� �pX CALic# �0\-138 Class,A <br /> R Insurer <br /> A Work Comp# <br /> c ICC Technician's Certification Number Expiration Date <br /> T sa a�t�\ - �T b-18 <br /> R ICC Installer's Certification Number �aS 6(oy'A- 1-tT Expiration Date \\- \(6-08 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T -?�- <br /> N 2 I ol< $ <br /> K 3 8 V, °1 <br /> P ElApproved Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) rr <br /> N Plan Reviewers Name Date <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 AGENTS 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signatu Title Date <br /> BILLING IN ORMATION: <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 the billing by signature and date below. <br /> NAME W tso"o TITLE PHONE# <br /> ADDRESS �. \ 0Asuoo <br /> SIGNATLIRE-,"_1Y 3 <br /> EH230038(revised 12/31/07) <br /> ? �.,.-.+.y:• 1.: '+'G { n "' a i, a _�s r1 -r ar h v f � �3� E� � x i r�?�,` ,� <br />