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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Alain 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 DALE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT WIPING REPAIR/RETROFIT OJUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# I O- W-eL4kat ,b 468-,;u 60 <br /> A ,r <br /> C Facility Name F( j� _1 Phone# :S-9q_ it iq <br /> I Address <br /> L ISOi �)aef� (o�1e, ���. � �4� CA 4'5-A� <br /> T. Cross-Street . q <br /> Y Owner/Operator WGk Phone# 02 Q -(� ( . ( 37,Y <br /> N <br /> t <br /> Conractor Name Phone# <br /> o SQW cce S'tfCcyl S S�Gtit$ _1 wC . {jg_ a i� (0 03 <br /> N Contractor Address L g Cdr q S(1;L- CA Lic# �gS /$� Class <br /> r u�NK �AU� 531 ( 14O Z <br /> A Insurer SZ 11(5u mtk et Co Work Comp# 33 j(D()Q <br /> ' <br /> T ICC Technicians Certification Number <br /> T Expiration Date <br /> D ICC Installer's Certification Number 9 <br /> R �.��S�7 4 — U�T Expiration Date ���g'6 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved laKpproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name AdItMA141, . A /JOtn d1t, Date b/2 /Zo Y <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: "I 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." <br /> Applicants Signature �D ��(k:e �� 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 different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signatureand date below. (? <br /> NAME_RQ,t/4iG k-V, Ula'(&4k" TITLE eC'4Ll®4aQ (-C 6WC-G/ PHONE# `t o— '3 4K) 4 <br /> ADDRESS O ( W tlrl(Il kU-� <br /> SIGNATURE ��j E t . ��• ��.�- ti G( �Lti✓ <br /> EH230038(revised 12/31/07) <br /> 1 <br />