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ENVIRONR*NTAL HEALTH DWARTMENT <br />SAN JOAQUIN COUNTY <br />600 East 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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑}� <br />UDC REPAIRJRFTRrnFIT I 1111 n <br />F <br />A <br />EPA Site "l.�A�42-0 <br />Project Contact & Telephone &)(2t � <br />C <br />I <br />Facility Name �v � '� <br />Phone#y(G3�c -2 <br />L <br />Address <br />Add3 Z2 Soy -Al" -e-in j` <br />T <br />Cross Street L S} <br />Y <br />Owner/Operator �Ao D N yi <br />Phone # ZpC _Ck -36 2- <br />C <br />o <br />Contractor Name � , � �� .• CYC 1L <br />Phone <br />T <br />Contractor Address CA q:�Lkt <br />CA Lic # I 2Z2Cj Class I)A <br />AInsurer <br />%.t - <br />Work Comp #', b -'l •10 - 01 <br />T <br />I ICC Technician's Certification Number 5�7j�rj - � � <br />Expiration Date 3 - t:,3- i p <br />R <br />I ICC Installer's Certification Number �j2��'j �j�� - U1.. <br />Expiration Date S-�5.- p� <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />❑Approved fpproved with conditions ❑Disapproved <br />L(SeeA <br />A <br />N <br />chment With Conditions) <br />Plan Reviewers Name Date 2 d� <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 <br />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 0 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 <br />CERTIFY <br />THAT IN THE PERFORMANC F T ORK FOR WHIC THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />, p a <br />Applicants`Signature Title / f �� Date X, �D SCI <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 �\ C ( TITLE P e S PHONE #__201 ' S-Lfr% <br />SIGNA <br />EH230038 (reviled 12/31/07) <br />