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6 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 344 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone: (249)468-3424 Fax: (209)458-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW`, <br /> TANK RETROFIT UPIPING R6PAIRIRETROFIT UUDG REPAIRlRETROFIT <br /> F EPA Si # nn !! Project Contact&Telephone# <br /> A fel Phone# D -� <br /> C Facility Name t <br /> Address (1 <br /> I Cross Street <br /> T <br /> Y Owner/Operator / Phone# <br /> C <br /> Contractor Name �� j , / r Phone <br /> N Contractor Address j' CA Lic!� rid/ Class f} A <br /> T _ <br /> AInsurer rQ rl - ' Work Comp <br /> T ICG Technician's Certification Number `' y$`j��` � Expiration Date <br /> T <br /> R LCC Instaliees Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P UApproved Approved with conditions UDisapproved <br /> L (See Attachment With Conditions) <br /> A -716 :2 <br /> N Plan Reviewers Name^ "I (7�L_ Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN GOUNTY ORDINANCES,STATE LAWS AND RULES AND REGUL ADONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL.HEALTH DEPARTMENT.OWNER OR LICENSED AGENPS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS LSSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A$TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOF?S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHI THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWNS <br /> OF CALIFORNIA." t <br /> AWp cwn S;grOI� Title (qdBate 1 ' <br /> BILI_ N FORMATION: <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 /> responsibility for the billing by signature and date below. <br /> NAME TLE PHONE,z, / u` <br /> ADDRESS <br /> SIGNATUR <br /> EH230038(revised 8!8!06) <br />