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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 /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW. <br /> UTANK RETROFIT UPIPING REPAWRETROFIT UUDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact 8 Telephone# <br /> Facility Name O- Phone <br /> I Address 0 <br /> I Cross Street <br /> T I <br /> Y OwnerlOperator S.. Phone jalnU <br /> C <br /> Contractor am Phone#,-26 - Z/& / <br /> N Contra r Add ss CA Lic# Q Class (tel <br /> T <br /> R <br /> Insurer <br /> Work Camp# <br /> A <br /> CICC Technician's Certification Number Expiration Data <br /> RICC Installers Certification Number Taboo Date <br /> Tank ID# Tank Size Chemicals S09 Cum:ntly/Pre ty Date UST Installed <br /> T <br /> A <br /> N <br /> K <br /> P LlApproved �,IAppmved with conditions UDisappmved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name f1wo (L(7 Date 101 <br /> APPLICANT MUST PERFORM ALL WORK.W ACCORDANCE WITH SAN JOAQUIN COUNTY FINANCES,STATE LAWS,.AND RIE$AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE FERFCRMANCE OF THE WORK FOR W4ICH THIS PERMrr IS ISSUED,I SHAH.NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKERS COMPETISA LAWS OF CALJFCRNIA" CONTRACTORUB <br /> S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. 't CrnFY <br /> THAT IN T!E PERFORM OF THE WORK FOR WHICH THIS PERMIT IS Ll®,I SHALL MPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicaris Sigatue T DeGe <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 parry designated below is different than the permit applicant, e.g. pro dy owner, the party must acknowledge this <br /> respo Miry for the billing by signature and date below. •- <br /> NAM - TI I/rTITLEJQ PHONE#49OT µ&/_U u <br /> q <br /> ADDRESS JJ / tLkA ^ <br /> SIGNATURE <br /> LE114Wn ) <br /> EH230038(revised&IBM) <br /> 1 <br />