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oxo�� <br /> ENVIRONMENTAL HEALTH. DEPARTMENT <br /> SAN JOAQUIN COUNTY; <br /> 600-East-Main-Street,Stockton,California 95202 — <br /> Telephone: (209)468-3420 Fax: (209)4683433 <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 /> ETTANK RETROFIT ❑ PIPING REPAIRfRETROFIT ❑ UDC REPAIRIRETROFIT C] COLD STARTIEVR UPGRADE <br /> Iite# Project Contact&Telephone# <br /> C ��Name it � Phone#s „Street <br /> /Operator Phonector:Name '�'� Phone# W9 461 ndctor Address A tJc# C(ass MW NY Work Comp#'Wf.63()9q17400 <br /> C <br /> r1CC <br /> 71nstallees <br /> ician's Mame Expiration Date <br /> T <br /> Q <br /> Expiration Date <br /> R <br /> ork area Tank Size Chemicals Stored Currently Date UST <br /> teclar,UDC 112,elc.1 - Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 14/I �4'� � . DateTa <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 AGENTS 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_PERS©N_IN SUCH&MANNER AS TO BECOME SUBJECT <br /> `TO-WORKER'S:COMPENSATION LAWS OF CALIFORNIA.-.CONTRACTOR'S HlRING.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' ,y c <br /> 6 <br /> Applicant's Signature lJlJIL[.kC� Title DVDale O ,F 6 <br /> BILLING INFORMATION: <br /> Indicate the responsible party.to be billed for additional EHD staff time expended beyond permit payment coverage per tank. It <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♦e.I& a b I)IQ&f� S r 1NCJ TITLE efffit�ffl a 6 _PHONE.#1 Ct1 CJ I <br /> ADDRESS 952jj i) <br /> I SIGNATOR _. _UATE <br /> EH230038(revised 02120109) <br />