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ENVIRONMENTAL HEALTH DEPARTMENT <br /> 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 1 AdR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THQHEE APPROVA DATE gl(JDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT APINGItEPA11 ETROFIT \ ❑UDC REPAIRIRETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A 4 <br /> C Facility Name K ( ot\ Phone# 200q— 6N - ZSS t1 <br /> Address <br /> I Cross Street <br /> T <br /> y Owner/Operator tc..J`S 430r, � \ Phone# 2Q`\_ 6y _2$$ <br /> oContractor Name L ` �� �� Phone# <br /> N Contractor Address '1Z-�5 pi\\ J2,roA2 CALic# 'Z, 'Z'L Class <br /> w" wL- <br /> A Insurer y�\ �"Sa 1 Work Comp# "21 L5 <br /> DICC Technician's Certificafion Number <br /> T Expiration Date � � p11 <br /> D ICC Installer's Certification Number �- <br /> R Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T \�Y <br /> N �� t04 i w.t ^ aSO�tP2 A , <br /> K <br /> P ❑Approved Approved with conditions []Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name �!/�� Date LO <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 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 VVH19H TgIS PERS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." '` <br /> Applicants Signal �-\\�` �ritle C^C Dale 1 �1 <br /> BILLING INFORMATION: <br /> Indicate the responsible party 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 /> responsibili for the billing by signature and date below. � <br /> NAME QN\ 1 1�"-`��' � /TITLEty��"'`]�� V\O'�5j� 4 <br /> PHONE <br /> #` ��r\ \) �/ <br /> ADDRESS �'\0 \A,( ��Wj AZOJ <br /> ���\ OJ C. bN'Vt'j` '�` 17Z11"b <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />