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r <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> r SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton, California 95202 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING itEeAR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE DICATE PERMIT TYPE BELOW: <br /> r / .11pp ;QVI 1hIC <br /> ❑TANK RETROFIT PINGkEpAIETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> r � Facility Name Phone# 24(\— 610 -2SS <br /> I Address 265 Sw c <br /> L <br /> TCross Street \L'ift. <br /> Y Owner/Operator p t.w,J.S Or, SSL-\ Phone# I W\— 6y <br /> D Contractor Name �,K,\� �, <br /> 0 Phone# <br /> N Contractor Address "7,Z.�S Pi\�V J2Y.v.2 CALic# 'Z <br /> r R Cc V; 1 Work Comp# 521 ZL 5 <br /> Insurer <br /> T ICC Technictan's Certification Number Expiration Date ( O`b <br /> r R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Cu rrently/Previously <br /> N <br /> K <br /> r <br /> r <br /> p ❑P.pproved Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) (� <br /> Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> r JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 9 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 OF CALIFORNIA-' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK F R WHIyH T►8S PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> ApprceMs \EEK//\\ 1� +�'Xf`� <br /> r \�C QF Orme r Dffie ,OW V <br /> Signet <br /> BILLING INFORMATION: <br /> Indicate the. responsibleparty to illed 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 /> responsibilikfor the billing eby signature and date below. om",, <br /> NAME \ o tA� Il^0�/, '`n {� TITLE 'Q' )Ql .w,�Q/'` PHONE• \�/`U'�., (`- 1 S V <br /> ADDRESS -LkID V"�•\� q-0Q <br /> r SIGNATURE <br /> EH230038(revised 8/8106) <br /> 1 <br /> r <br />