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11/10/2010 07:16 5307499892 MIDVALLEY CONSULTING PAGE 02 <br /> O.. V <br /> 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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TWE BELOW: <br /> OTANK RETROFIT O PIPING REPAIRIREMCIFIT O UDC REPAIR/RETROFIT O COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � <br /> Facility Name '� rc Phone# (? <br /> L <br /> Address 19 I <br /> I Cross Street <br /> T _ Phone# <br /> Y Owner/operator <br /> c Contractor Name Phone#S p— r7 ' y <br /> N Contractor Address r vc� w C Lic# Zo Gass /4 <br /> R Insurer Work Comp# <br /> A <br /> IGC Tedmician's Name �. Expiration Date ,5✓ p <br /> Op ICC Installer's Name S Expiration Date Z VOID <br /> stem work area Date UST <br /> Tank <br /> pa.rr pp„gs oo st I..��. 'UO I&,aGl Tank Site Chemicals Stored Currently Metalled <br /> T 7 I•( �m D 6� 'j//) ��PhU£A a DO S' <br /> A <br /> N <br /> K <br /> P ❑ Approved '''Approved with conditions U Disapproved <br /> L See meet With Conditions) <br /> A <br /> N Plan Reviewers Name �L-- Date ��i— /O <br /> APPLICANT MUST PERFORM ALL WIRK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWMER OR LICENSED AGENT`S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WQRi7-RS COMPENSATUT�tiWiS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUSCONTRAC TING SIGNATURE CERnrics THE FOLLOVNNG' I CERTIFY <br /> THAT IN THE PE.RFORMANC F K FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA.' /J <br /> Apd ^T9 signelue t r /� Daoa d/ <br /> BILLING INFORMATION: <br /> Indicate the rewon I le party to be biped for additional EMD staff time expended beyond permit payment coverage per <br /> tank If the party designated below is different than the permit applicant,e.g. property owner,the parry must acknowledge <br /> this responsibility for the billing by signature and date below, <br /> NAME DA U TITLE o PHONE <br /> ADDRESS f0 <br /> . SIGNATURE DATE <br /> EI-12"30( 122!10) <br /> 2 <br />