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ENVIRONME14TAL 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 TYPE BELOW: <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />Facility Name Mt. 11411t, <br />t . 14 SoV e S <br />Phone 6610 <br />� <br />Address Oji �/' <br />./ <br />C�IN <br />TCross <br />Street <br />Y <br />Owner/Operator <br />vin2 ,-'U 5 <br />Phone # 00 -- - 6 — 37Z— <br />oContractor <br />Name <br />p;.� <br />Phone # �Cf b — 4' <br />N <br />T <br />Contractor Address U <br />�� 38(� <br />CA Lic # p �j Class <br />R <br />Insurer t Y`� <br />Work Comp # ')()Q 5 tag - Z <br />T <br />ICC Technician's Certification Number <br />? WO 5 <br />Expiration Date�'�� <br />Q <br />R <br />ICC Installer's Certification Number <br />—ZS' Oir j Z <br />Expiration Date tj <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />r —(7&10110W <br />T <br />A <br />N <br />r <br />tS <br />e <br />K <br />P <br />❑Approved <br />Approved with conditions ❑Disapproved <br />L <br />(Se Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date_a 12�� <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE <br />WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />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." <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFORMANCE OF TH RK FOR WHICH <br />THIS PERMIT IS ISS ED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." r <br />Applicants Signature <br />Title ✓� �- Date <br />BILLING 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 differe t than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility r the b'/ grb ''sig ®t re nd date below. % 7 <br />NAME � � �l l IT rn TITLE PHONE # <br />ADDRE <br />SIGNATUR <br />EH230038 (revised 12/31/07) <br />1 <br />JI"OG <br />