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Work Order: 2254987 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone:(209)468-3420 Fax:(209)469-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES SD DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW <br /> ._ I.ITAWLRETROFIT .61 MC REPAIRBETROFIT <br /> F EPA She N I-IVOC REPAIRJRETRCFIT <br /> A I Prolect COntect 8 Telephone N <br /> C Facility Named, -11615 <br /> amed, <br /> � Address /53 f I( � �y b 04 <br /> ce <br /> T PnoneN yo9-8 801 <br /> I Cross Street <br /> Y Owner/Operator <br /> o Contractor Name n C o 1 o Phone N <br /> TContractor Address 77 ! ��� 4 PhoneN <br /> R Insurer LICK -14 ,3ti O Class <br /> A ra.Llc Cr /.tel + work Com <br /> T ICC Tecnnigan's CertipN 9 .L4� <br /> fication Number <br /> 0 ver 5 3(P7 b(. Expiration Date <br /> R ICC Installer's Codification Number <br /> Expiration Data <br /> Tank ID N Tank Size Chemicals Stored <br /> Currendy/Previously Date UST installed <br /> T <br /> A <br /> N <br /> N <br /> (Approved <br /> L LIAPproved with conditions I IDIsapProved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> Date <br /> APPLICANT MUST PERFORM ALL PORK IN ACCORDANCE NTH 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 FOLLOw1NG: t CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR W CH THIS PERMIT IS SWED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKEA'S COMPENSATION LAWS OF CALIFORNIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: T CERTIFY <br /> THAT IN THE IA,'PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO MWERS COMPENSATION LAWS <br /> OF CALIFORNIA. <br /> ApGl"ni,Ii Sig.. Tile O� '-+L <br /> /Y12JC@ .l Dae --/2-06 <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 /> responsibility for the billing by signature and date below. <br /> NAME TITLE <br /> PHONEN <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised E/3B7) <br /> 1 <br /> Tanknology Inc. 8501 N. MoPac Expressway, Suite 400,Austin,Texas 78759 <br />