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ENVIRONMENTAL HEALTH DEPARTMENT � <br /> SAN JOAQUIN COUNTY tp <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420' Fax: (209) 468-3433 <br /> L <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 /> r� 1'-.TANK RETROFIT I- "IPIPING REPAIRIRETROFIT I._]UDC REPAIRlRETROFIT <br /> I F EPA Site# Project Contact&Telephone# <br /> Facility Name ! yl - UU o01 S — Phone# <br /> I Address j tjU 1 � �- �p 1�� pV1 CA cj 53 <br /> T Cross Street - <br /> Phone# <br /> Y Owner/Operator -- <br /> o - Contractor Name L �uL Phone# ^ <br /> N Contractor Address I. L L U (.L7 (� Ltacrt LAi CA Lic#7�/"/' d Class <br /> T <br /> • Work Comp# 3y Z.(Z(v��j• <br /> Insurer yt IG LjZ� i [os� n - -` <br /> C Expiration Date <br /> T ICC Technician's Certification Number--�,— — — <br /> D - Expiration Date <br /> R ICC Installer's Certification Number _ — ----- <br /> ------------ ------- --— ----- Chemicals Stored <br /> Tank Size Date UST Installed <br /> Tank ID# Currently/Previously <br /> T - --- --- <br /> A ----- <br /> N --- - <br /> K <br /> P I. <br /> (Approved - I- (Approved with conditions �....�Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date T- <br /> LATIONS <br /> APPLICANT MUSTPENVIRONMENTALRFM ALLRK INA DEPARTMENT.WITOWNER OR LICENSOED UNTY AGOENT'S SIGNRDINANCESURE CERT F ES THE FOE LOWING:AND "I CERTIFY TOHATAIN <br /> N <br /> JOAQU COUNTY <br /> THE <br /> WORKER'S PERFORMANCE <br /> SO T H LAWS OF CALIFORNIA."IPERM <br /> CONTRACTOR S HIT IS ISSUED, IRING GOR SHALL NSUBCONOTRACTINGRSIGNATURE CERTIIFIESRTHE FOLAS TO BLOW NG SUECOME BCERT IJECT F <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." �/� /DZ�/p S7 <br /> Title ln,4 � 6-eli�/1�i8' Date / u <br /> Applicants Signature 1 -' <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 <br /> TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/3/07) <br /> 1 <br />