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4987 <br /> Work Order: 225 <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 Se DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE aELOW: <br /> L(TANK RETROFIT .I PIPINGREPAIWRETROFIT LIUDO REPAIR/RETROFIT <br /> F EPA Site# Project Conlacl 8 Telephone# <br /> A Phone#209-82 891 <br /> C Facility Nam Lk CU C.0 3(0 <br /> I Address 15 3 E I t 4�h- bl� G✓J 5 to <br /> T Cross Street Phone# <br /> Y Owner/Operator <br /> Phone# - db 6-IZKIo <br /> C <br /> Contractor Name � ,L,IL nok o _ Class <br /> T Contractor Address 7�/ f 4X I�fe/u! 45 A LIC# -1'-L ,31 to O <br /> f_ Work Comp# <br /> A Insurer rgq,IL(r /,cl + tAJ1H1 Expiration Date <br /> T ICC Technician's C <br /> Dertification Number,) ,L,{-, ,l iL rKI' 5 3676(0 <br /> Expiration Date <br /> R ICC Installers Certification Number <br /> Tank Size Chemicals Stored Date UST Installed <br /> Tank ID# CurrenllylPreviously <br /> T <br /> A <br /> N <br /> K <br /> P <br /> ]Approved LiApproved with conditions I. (Disapproved <br /> L (See Attachment With Conditions) <br /> A Date <br /> N Plan Reviewers Name <br /> LAWS,8 STATE AND RULES AND SON IN SUCH A MANNER AS To E TI <br /> APPLICANT <br /> MUST <br /> RALL <br /> WOHIN ACCORDANCE <br /> WTHSAN <br /> QUINDEM� RS THE FOLLOWING n CERT`Y. TIN <br /> JOAOUIN COUNTY, F ENVIRONMENTAL O NSEGSGN ORE CEIBECOME BJECTTO <br /> THE WORKERS COMPENSATION OFTITHE <br /> WORK FOR WHICH OFC ORNIAISPCRMONTRACTOR SIT IS DHIIRINGL OR SUBCONfRATCINGL NOT EMPtOy ANY I RSIGNATURE CERTIFIES THE FOLLOWING:�1 CERTFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I sHALL EMPLOY PERSONS SUBJECT TO WORKIB"COMPENSATION LAWS <br /> OF CALIFORNIA.- -12-op, <br /> Thle Of-1A1 c �� Date <br /> rop1CBn°S's081Wa BILLING INFORMATION: <br /> Indicate the responsible parry to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the parry 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. PHONE# <br /> TITLE <br /> NAME <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/3/07) <br /> 1 <br /> Tanknology Inc. 8501 N.MoPac Expressway,Suite 400,Austin,Texas 78759 <br />