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05118/2009 17:46 2093651543 <br />40 <br />TANKNOLOGY <br />E <br />COUNTYENVIRONMENTAL HEALTH DEPARTME <br />SAN JOAQUIN <br />600 East Main Street, Stockton, California t, <br />Iti IFax:r468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPO BELOW: <br />CI TANK RETROFIT ❑ PIPING REIPAIR/RETROFIT 0 UDC REPAIRIRETROFIT Ci COLD ST <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />F <br />L <br />A <br />N <br />EPA Site # <br />Facility Name �. <br />Address oZ 3 bi <br />Cross Street <br />Owner/Operator <br />Contractor Name,?, <br />Contractor Address <br />ICC Technician's No <br />ICC Installer's Dame <br />e <br />Tank system work area <br />(I,o, 87 plpl)a sump, 91 kmk detWor, UMC 117„ M) <br />r] Approved <br />Plan Reviewers Name <br />Project Contact & Telephone # <br />Phone # <br />Phone # <br />Phone #Z&q - <br />t� Ltrd: C14 4 CAI_iC# Ott-1`�IbO <br />Work Comp # ' <br />® LLQ Expiration Date <br />Expiration Date <br />Tank Size Chemicals Stored Currently <br />I l Approved with Conditions r <br />(See Attachment With Conditions) <br />PAGE 02/08 <br />t <br />UPGRADE <br />lass <br />�?.� <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES At D REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLIA ING; "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 NS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN TME PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKE S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Indicate the responsible party to be biped for additional EHD staff time expended beyond permit payment cover ge per tank. If <br />the party designated below is different than the permit applicant, e.g, property owner, the party must a:knowledge this <br />responsibility for the billing by signature and date below, <br />NAME ---.-TITLE PHONE # <br />I_lelel:]�-Ly <br />SIGNATURE DA <br />EH230038 (revised 02/20!09) <br />I <br />