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From: 0 1216008 16.43 #216 P.005f007 <br />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 TYPE BELOW: <br />TANK RETROFIT Y�PIPING RELI <br />UDC UDC REPAIR]RETROFIT I._. COLD STARTIEVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone <br />A <br />G <br />Facility NameOe�c,L <br />Ph ne # <br />Address {p r�'j Gid Y' <br />I <br />Cross Street <br />Y <br />Owner/Operator ' t <br />Phone 71?) �-A 00 <br />2-41T <br />C <br />Contractor Name <br />ch '�'a <br />Phone c?)6M P(o <br />T <br />Contractor Address q£'SZIS c� CA Lie # ' �j Classd 6L <br />R <br />a <br />Insurer <br />Work Comp # <br />T <br />ICC Technician's Certification Number 5,3LS aC - " LA 1 <br />Expiration Date Gl v � <br />R <br />ICC Installer's Certification Number I��— LA 1 <br />Expiration Date �yrti 2 c� 12cI <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date (1ST Installed <br />GI d <br />L <br />T <br />A <br />N <br />K <br />P <br />' Approved – pproved with conditions Disapproved <br />L <br />A <br />ee Attacbrryent With Conditions) <br />/ <br />N <br />Pian Reviewers Name � Date e ee <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN 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 FOR HICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA," <br />Pf <br />Applicants Signature Z11 Title I0,- 4 lJ' Date <br />BILLING INFMMATION" <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 �CV1TITLE PHaNE # C `Ce/ 1 4 <br />ADDRES', <br />SIGNATU <br />EH230038 (revised 12/31107) <br />EA <br />7 <br />