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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 /> (I--77 THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> LJTANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT <br /> FF EPA Site# Project Contact&Telephone# _Nm y �f(jk-(0551 <br /> C Facility Name Che Phone# _ 5 <br /> � Address <br /> I <br /> TCross Street <br /> - _ <br /> Y Owner/Operator 'Step. Phone# -(A46 <br /> C Contractor Name <br /> O 1 , Phone.#2M Akk Aa--1 <br /> T Contractor Address _15[1 3CY1 CA tic# �(� Class <br /> R <br /> Insurer Work Comp# _ <br /> Technician's Certification Number <br /> T ICC ThCtifitiExpiration Date <br /> o ICC Installer's Certification Number Expiration xpiration Dale <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> A <br /> N -- <br /> K <br /> P ❑Approvedproved with conditions ❑Disapproved <br /> L ( ee AttachSment With Conditions) <br /> A <br /> N Plan Reviewers Name - Date <br /> APPLICANT MUST PERFORM'ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RILES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THC PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLO f ANY PERSON IN SUCH A MANNERAS 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,1 SHALL EMPLOY FERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> Applicants Signatue6m uok& Tide <br /> _ _Dale _+ <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyund-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. - --t <br /> NAM E I f t�1L� } —TITLE-�y�p5 } _,.PHONE# 2C�� I <br /> ADDRr_SS <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br />