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!2008 08: 24 20j40138 ENVIRONMENTPAIHEALTH PAGE 02/07 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East blain 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 100 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT.TYPE BELOW: <br /> TANK RETROFIT IP NG REPAIR/R ❑UDC REPAIR/RETROFIT ❑COLD STARTIEVR UPGRADE <br /> EPA Site# Project Contact 8 Telephone#M\V_ 3S3 <br /> =acility Name — Phone# Cc � <br /> Addresses . <br /> Cross Street <br /> Own orator Phone#;2. yQ Z— r <br /> Contractor Nam c' =aMQA- 'r Phone# <br /> Contractor Address , CA Lic#3' Clas <br /> usurer Work Comp# 01 Z <br /> .T ICC Technician's CoNfiation Number Expiration Date <br /> a ICC Installer's Certlficstion Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored CuDate UST Installed <br /> nantly/Previously <br /> c� <br /> N <br /> K <br /> 1 � <br /> �Y ❑Approved / Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) / <br /> N Plan Reviewers Name Date_i ID l W <br /> APPLICANT MUST PERFOR AL1 WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> : 'OAOUIN COUNTY, ENVIRONMENT LHEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 11 CERTIFY THAT IN <br /> THE PERT- <br /> —Tim <br /> WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> ADR✓.E OU F C ONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> !HAT IN THEOf T WORK FOR WHICH ERMIT Is ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNI <br /> .:pPicerrts Syn <br /> BILLING IN ORMATION: <br /> ,ndlcate me responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> me party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> ,esoonsibility for the billing by signature and date below. <br /> �;;.1ETMltCtQ ;P16t til TITLE Q JLA^tj9kF== PHONES Z09 <br /> =00RESS s0 C.Iq"q 2 roc !f:� CIS-7 0 (o <br /> GNATURE <br /> EH230038(revised 12/31107) <br /> 1 <br />