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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 90 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW'. <br /> I.ITANK RETROFIT DIPPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A Facility Name Lk14.,-& ,M6e- LU W 2)(o o Phone#Zo9-92, 801 <br /> L Address i 5 3 E f t �' b4- G✓J 5 b <br /> TCross Street <br /> Y Owner/Operator Phone# <br /> D Contractor Name Phone# - ai-d-i 2-Lt(p <br /> D 0.n. C../�O�o <br /> N Contractor Address rj�J ` LW/fi /r� OrFI- �+� A Lic# -'1 Li ,fit( CJ Class <br /> T <br /> R Insurer �rgh,lt (� /,OI 4 Cam Work Comp# 3N -LC(-( <br /> A <br /> TICC Technician's Certification Number ,U.(.� �. /' SX 3 6'7 S Expiration Date _ t1- $ <br /> R <br /> ICC Installer's Certification Number Expiration Date <br /> Chemicals Stored Date UST Installed <br /> Tank ID# Tank Size Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P DAD oved Approved with conditions UDisapproved <br /> L (Se Attachment With Conditions) <br /> A 4�9 <br /> U OY <br /> N Plan Reviewers Name Date <br /> MUST PERFORM ALL WORK IN ACCORDANCE WITH SA QUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> JOAQU NNCOUNTY. ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING'REGULATIONS CERTIFYTOA <br /> 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 WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" �2—OE' <br /> r//'��t �- <br /> Applicants Signature <br /> Title OY+' <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 PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/3/07) <br /> 1 <br />