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12e24/2008 14:13 FAX 91637125 SZMAINT X1001 <br />0 <br />D u L� <br />ENVIRONMENTAL HEALTH DEPARTM6e= <br />SAINT JOAQUIN COUNTY .IAN 12 2009 <br />600 East Main Street, Stockton, California 95202 ENVIRONMENT HEALTH <br />Telephone: (209) 468-3420 Fax: (204) 468-3433 PERMIT/SERVICES <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXP(RES 190 DAYS FROM THE APPROVAL DATE. INDICATE PERMI "1'PE DDELOW: <br />L. IPIPING REPAERlFRETROFIT ❑Ut7C REPAI!ilREFROF{r <br />LICOLD STARTIEVR UPGRAD <br />C'TANK RETROMT <br />ERA Site # Prajeot Contact & 7eiephone # <br />Phors # -)-09) 9 S E <br />Facility Name PC -000 �S <br />Address J� I!� e . f� . �j I c.1 <br />Cross Street ECy—M <br />owner.'Cperator St,, Phone # t <br />Contractor Narne (� . �. Mow ✓`ita-n `�'^� Phone # I b <br />CA. i-ic # Gess <br />Contractor Address n HO u '-*TV ti 57A. <br />Sot II I i <br />Insurer <br />ICC Technician's Certifioation Number <br />ICG In -,jailer's Certification Number_ <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />0 <br />N <br />T <br />R <br />A <br />G <br />T <br />4 <br />R <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />Tank ID # <br />Approved <br />work Comp # <br />Expiration date <br />Expiration Date <br />Tank Size Chemicaia Stored tate U5T installed <br />Currently)Previously _ <br />Approved with conditions LiDii;approved <br />(See Attachment With Conditions) <br />Plan Reviewers Name_ date <br />APPLICANT MUST PERFORM ALL WORK tri ACCORDANCE YWTH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, ANP RULES ANO REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENT& HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PER.FORMANGE OF THre WORK FOR MCH THIS PERMIT IS ISSUED, I r:H61.I. NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CA, fr NLA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE C,,ernInIES TME FOLI.OWINQ: 9 CERTIFY <br />THAT IN THE PERFORMANCA OF THE _ R WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br />OF CALIFORNIA." ^ � <br />Indicate the responsible party to be billed for additional EHE) staff time expanded beyond permit <br />P�nY mu t acknowledgloverage par nk, If <br />the party designated below is aifterent than the permit applicant, e.g. property owner, <br />responsibility for the baling by signature and date below. <br />NAME � TITLE — /77 <br />�. <br />.........�.. � � � � • 3C1 �, ���� � o �� [ � � �� Lam_ <br />CIGNA' <br />EH23oD88 (revised 1=1177) <br />X <br />