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1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 Fast 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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> I ITANK RETROFIT L_6IPING REPAIR/RETROFIT L_IUDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A _ <br /> C Facility Name '- �� I 11 05-000-13Phone# Zd`J- 5179_ If/ <br /> Address 160 v 1 M jc c� -T0 t,1 c R-ak 0 n CA Q 53 (,e (o <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> 0 Contractor Name A_*XkwoW c. 1NL Phone# <br /> T Contractor Address [ l L U W , 1C.e " LN CA Lic#7y-3/&b Class <br /> R Insurer Work Com # <br /> A �hkC �I '�Lo� a�. p 3yZlc�v_�-�t�l <br /> TICC Technician's Certification Number Expiration Date <br /> RICC Installer's Certification Number 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 I ]Approved r1�<pproved with conditions LIDisapproved <br /> L (See Attachment With Conditions) <br /> A tr <br /> N Plan Reviewers Name I`� Date �6/Crr7 <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 Title Q114 Ce �� 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 signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/3/07) <br /> 1 <br />