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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 TYPE BELOW: <br /> TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# UJ ca ztk u �IpP (3-(Q0� <br /> A <br /> D Facility Name �/��1� Phone# <br /> L Address <br /> I Cross Street =' S <br /> T <br /> Y Owner/Operator Sktc(,L b<< Phone# 3 jp- <br /> o Contractor Name $ ��„�441!cc " tz,tws� j w , Phone# -i(1 <br /> N Contractor Address <br /> T 3'0,tAc{ Auk ss 6 4S<<a. CALic#t(-t V 1-4 Class`s C&i1,6q0 <br /> A Insurer C S uSL�YF-cICC e co Work Comp#3t j OO,-U%.,3(CC) <br /> T ICC Technician's Certification Number <br /> 53 C�S.�74 .. C)7" Expiration Date a <br /> QICC Installer's Certification Number <br /> R Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved pproved with conditions ❑Disapproved <br /> L SeAttachment With Conditions) <br /> A <br /> N Plan Reviewers NameA It hill I 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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 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." i <br /> ApplicantsSignature �LLLi.'�,'" Ck � til% Title " <br /> Date t �L.' <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 /> NAME arl�,Ttid-1 �' w�L i- _ � -- <br /> TITLE UIZ1K 8 �J«'VpHONE# [l <br /> ADDRESS b 0 <br /> SIGNATURE jj4(A t_i LLLA`- <br /> EH230038(revised 12/31/07) <br /> 1 <br />