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P� <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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT YYPE BELOW: <br />TANK RETROFIT OPIPING REPAIR/RFTROFIT nI me aG0e1010cr0nn1r n...,..•. —..,,-n <br />F <br />A <br />- <br />EPA Site # <br />--------.—_—_••—•••••••••�••.....,. uvvw u t me llcYl[Vr'L7tWVc, <br />Project Contact & Telephone # "Al <br />D <br />Facility Name a 0Phone # <br />209 M5 —a2eRt+ <br />� <br />Address 6 UnLin r- - - <br />uc <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator �' <br />Phone # _ <br />cContractor <br />Name �Z <br />Phone # _ <br />N <br />N <br />T <br />RInsurer <br />Contractor Address <br />CA Irc # WI Class <br />AXP( <br />g Work Comp #W� <br />T <br />ICC Technician's Certification Number Expiration Date <br />R <br />ICC Installer's Certification Number Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />LApproved <br />proved with conditions ❑Disapproved <br />A <br />(See Attachment With Conditions) <br />N <br />Pian Reviewers Name r�J{,�r-.— Date_ U 1,0 <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 'I <br />CERTIFIES THE FOLLOWING: 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: '1 <br />CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA' <br />,, �VVx <br />Applicants Signature �( �1�/`� - � Title Ipl-e (1(P�PY�irl 1 V I r.._ (YO <br />v <br />BILLING IN RMATION: <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 />SIGNATU� r <br />EH230038 (revised 12/31/07) <br />9 <br />