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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 /> TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT <br /> F EPA Site# Project Contact&Telephone# pa.'. i.R6R3 <br /> � Facility Name 41 tot o Phon 2M•OVIq <br /> � Address 44143 q <br /> I Cross Street n <br /> Y Owner/Operator <br /> oContractor Name L � _ Phone# <br /> IN T Contractor Address pp CA Lie# j'�a3S Class '� 2 <br /> R Insurer Work Comp# <br /> A <br /> DICC Technician's Certification Number (� Expiration Date (� <br /> T <br /> a ICC Installer's Certification Number a, Expiration Date �j zook <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T Ks k Aoi,, <br /> A <br /> N <br /> K <br /> P Approves' Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) p <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN 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 QF CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OFT WHICH THIS PERMIT ISSUED,11 SWALL EMPLOY PERSONS SUBJECT T WN LAWS <br /> OF CALIFORNIA." <br /> Appliwrns Signature Title VM& UM Date 1� <br /> BILLING INFORMATION: <br /> Indicate the responsible p rty to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party desi nated below is different than the permit ap{�licanI, e.g. property owner, the party must acknowledge this <br /> respo sibility f the billi by signature as nd to below. <br /> NAM I <br /> X11 1( ,tl�(( TITLE -PHCNE# Ca l�/I•'7(!j'I tJ <br /> ADDRESS U ry• o/41 ASPO-1 <br /> SIGNATURE �� L <br /> EH230038(revised 8/3/07) <br /> 1 <br />