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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor, Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> ����.. <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 99<NK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFII' <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name �<Cll Phone# 2 O cl na . ;?7c2 -k <br /> IAddress <br /> L Y E. <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> C Contractor Name cin �i 4rr+ Phone# 6�, /- 3 G �- 74/00 <br /> T Contractor Address Yob TGn le.r GALiC# etoY-3 Class <br /> R Insurer /`i�i,dsp.9 �rrJF,,rgi, L Work Comp# ��So6,�s�07 <br /> G <br /> T ICC Technician's Certification Number Expiration Date <br /> RD ICC Installer's Certification Number O �7 ^J ��'/— 6e Expiration Date <br /> Tank Ill Tank Size Chemicals Stored Date UST Installed <br /> currency/Previously <br /> T J —Z 7 ax Yj G30(/YJ Pr <br /> A <br /> N <br /> K <br /> P ❑Approved li;Wproved With conditions UDEapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name�`�/�ir'�' L` a, Date 1 [ I Q8 <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 SUBJEOT'r0 <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 SMALL EMPLOY PERSONS susiECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> AppllcanIs Signalura / Title <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional El 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 signatu�j and date below. <br /> NAME ��� TITLE ,A PHONE! <br /> ADDRESS a 5'OU S�� i,3ru.ito v� 54,E ��eir</Seea C .. <1 <br /> SIGNATURE" <br /> EHP60036(reviaeo 6/6/06) <br /> 7 <br /> L0/b0 39Cd -1-IIH ADAHO E2',9EE6ET99 bE:TT 800Z/TZ/40 <br />