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06/13/2008 11:45 2093651510 TANKNOLOGY PAGE 01/05 <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 UN'DERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PjR11IT <br /> THIS PERMIT EXPIRES SO DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW, <br /> I-1rAm(RETROFIT I]PRISIG REPAIRIRETROFIT nuoc REPAIR/RETROFIT <br /> F EPA She# - Project Contact&Teleptione# <br /> A <br /> C Facility Name I n a, —T U!;-,-O DO-? Phone# Z-07- 6 If <br /> I Address I <br /> L —ro"r- [Iv Ron __.CA 9 53 le 6 <br /> Icross street <br /> T <br /> Y Owner/Operator Phone <br /> C Contractor Name <br /> 0 L b U Phone;ft <br /> N Contractor AddreS., Class <br /> T Aj lift;11-7q3l 6-0 <br /> R w— <br /> A -Insurer fi-4n be LfZq'l4-%I 1 coma'a'w WDrkCOMP# JE/-Z4&"�f, <br /> C <br /> ICC Technician's Certification Number Expiration Date <br /> i <br /> ICC Installer's Certification Number Expiration Date <br /> Tanl(ID# Tank Size Chemicals Stored Date UST lnst�lled <br /> Currently/Previously <br /> A <br /> N <br /> P I.lApproved 1--lApproved with conditions 1-.IDisapproved <br /> L (see Attachment With Conditions) <br /> A <br /> N <br /> Plan Reviewers Name Dato <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 CURT*THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> INORKERS COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY <br /> THAT IN THE PIERFORMANGE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL EMPLOY PERSONS SU8JFCT TO WORKER'S COMPENSA11014 LAWS <br /> OF CALIFORNIA' <br /> AppllronO$19nifurk Pat <br /> ;7-- BILLING INFORMATION. <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment GovCraae per tink.j 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 dole below. <br /> NAME TITLE PHONE <br /> ADDRESS_ <br /> SIGNATURE, <br /> CH230035(revised 813/07) <br />