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jun.09.2010 10:33 AM PAGE. 2f 3 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209) 468-33420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THUS PERMIT EXPIRGS 18v DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW'. <br /> ❑ TANK RETRomi' ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact 8r Telephone# <br /> Facility Name ,,,.� Phone# <br /> Address _ �`�` ` <br /> I <br /> Gross Street - --� -- ---� <br /> T AL I � Phone# <br /> Y pwnerl6perator JCl,r("a_�tL� -- <br /> c Contractor Name' yPhone# -, <br /> 0 Contractor Address CA LIC# Class. <br /> TWork Comp# <br /> r cY 7 <br /> R Insure <br /> GICC Technician's Name Expiration Date - -� <br /> T <br /> R ICC Installer's Name _ Expiration pate <br /> y Date UST <br /> Tank system work ea Tank Size Chemicals Stored Currently Instalied <br /> (i.5.07 ptOA9 SUM.91 leak datect9r,uoc to etc.) - <br /> A v CJ v <br /> IN <br /> c� I <br /> v <br /> P n Approved P�'Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A -10 <br /> N Plan Reviewers Name r nate b� <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 KEALTh DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERT}FIE$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 <br /> TO WORKER'S COMPENSATION LAW'S 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 15 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'�COMPENSATION LAWS <br /> OF CALIFORNIA,' � n7 yIl <br /> AgpIIGdCct's 618rlakur =`'� """ Q Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD Staff time expended beyond permit payment coverage <br /> per <br /> tanek. 111 <br /> l <br /> the party designated below is different than the permit applicant, e.g. property owner, the patty 9 <br /> responsibility for the billing by slgnat�re and date below, <br /> \� ' 15Rtwl�- U � T1TLE1 ` PHONER <br /> —TITLE <br /> \ ADDRESS <br /> DATE <br /> SIGNATtJR , <br /> EH230038(rftSed 02!20109) <br /> i <br />