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ENVIRONMENTAL HEALTH DEPARTMENT <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 TWE BELOW. <br /> ❑TANK RETROFIT ❑PIPING REPAIPJRETROFIT ❑UDC REPAIRIRETROFIT OLD START"UPGRADE <br /> F EPA Sits:#, C I 5Project Contact&Telephone# <br /> � Facility Name e4-eZ Lk) C-h-evrcrn I Phone# 20c� y(p5-- 3,4yo <br /> LAddress <br /> T Cross Street L t V-Nut ST . <br /> Y Owner/Operator y Phone# (20 O(ga— (� <br /> racteoContor Namable- C Phone# (2oq S— 253(p�j <br /> N <br /> T Contractor Address , ' t- l S CA Lic# '�('�b Class A <br /> R <br /> Insurer LYGY� Work Comp# N /q . <br /> T ICC Technician's Certification Number O — Expiration Date Lf - 1 (0 - <br /> DICC Installer's Certification Number aS y (� _ V ' Expiration Date <br /> R I ' t� <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved X7pproved with conditions []Disapproved <br /> L Be Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 0 r/ <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 AGENTS 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 PERFOR CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKEWS PENSATION LAWS <br /> OF CALIFORNIA' //�,, /�/� �j�y�-/�9�, y� <br /> Applicants Signature �C-Pi 4 lL(l Title U/ / l l �4_.N v 2 Date l z /7 Cl <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 /> responslb(')I�'ity for the <br /> ybilling <br /> �bpy�signature <br /> `/,and date below. �p� ql t t � ( I /� <br /> NAME ✓ "f-1 r Y�CI 02 J. J0/��TITLE �GU 17 �y � PHONE#���f/ �1����-I Lt V <br /> ADDRESS SU r <br /> SIGNATURIE <br /> EH230038(revised 12131/07) <br /> 1 <br />