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Juh.09.2010 10:33 APR � 0 PAGE. 2/ 3 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 45242 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TH18 PERMIT EXPIRE$180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK R67ROPIT U PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD$TARTIEYR UPGRADE <br /> F EPA$Ze; <br /> A Project Contact Telephone <br /> C Fodity Name t� Phone A C9 <br /> IAddress <br /> TI Cross street <br /> Y <br /> ownerloper$tor ar4u � I p"t !Shone# <br /> 0 Contractor Mame PhgnB# <br /> N ContractorAddress ,� <br /> R CA SIG# Gass <br /> A Insurer > Work Camp#l <br /> T ICC Technician's Name <br /> o r ..0 r Expiration Dale ct -a <br /> R ICC Installer's Name Expiraiion Date I <br /> Tank system work a Tank Sire Chemicals Mored Currant! Date UST <br /> {i.c.87pc„mp,gt leek del9atar,L=U2,glC.j y InStaliBd <br /> T t '(� <br /> A —` <br /> IN <br /> K ..4 its <br /> td <br /> P ❑ Approved ❑ ApprovW with coed tions ❑ Clisapproved <br /> A (See Rttwhrrient With Conditions) <br /> N Plan Reviewers Name <br /> Coto <br /> APPLLCANT MUSY PERFORM ALL WORK EN ACCORDANCE NTH SAN JOAQUIN COUNTY ORCINANCES,STATE LAVVS,AND RULES ANO REGULATIONS Of SAN <br /> JOM UIN COUNTY,ENVIRONMENTAL HNALTH DEPARTMCNT.OWtMER OR LICENSED AGENTS SIGNATURE`CERTIFIE$THE FOLLOWING "t CERTIFY THAT IN <br /> THGi PERI 08MANGE 4P THe V40AK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EkIPLOy ANY pER90N IN SUCH A MANNER ABECOME SUBJECT <br /> S TO <br /> TO NKIRNER'$COAAPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING 51GNATURE CERYIPIE$THE FpLLOWIN¢: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I$HALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> QFCALIfORNIA" � <br /> AppllarnC9519n�tur TI88 DE19 <br /> BILLING INFORMATION- <br /> Indicate the responsible party to be billed for additit3nai EHD staff time expended beyond permit payment coverage per tank. if <br /> the party designated below is different than the permit eppticert, e.g, property owner. the party must acknowledge this <br /> reseonsibiiity for the billing by signature and date below. <br /> NItNI� 11�- �A i J � T1TL1; >� '� �6 PHONE# (��9 f f <br /> try � <br /> ADDRESS l "` f T° �. cii 3 b <br /> SIGNATURL-� YJ ` ;- „ DATE <br /> EH230038(revised=2010s) <br /> 1 <br /> f <br />