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ENVIRONMIPENTAL 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 RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT X UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name 0.,mn19jLkIaCZ Phone# ,%, q-933 ")'] <br /> I Address NPA LA. rk0AW 141& +n, CA g5a6 <br /> I Cross Street <br /> T <br /> Y Owner/Operator }'pQt� irihitI at,h Phone# 40q- 'tI10 •40 1 <br /> o Contractor Name Z VAC C0 Phone# I(p 360 <br /> T Contractor Address ,l>,1�JOX 9'33 i;�(�rn¢,.tl}e 9904 CA Lic# '�33/ Class $- 7� <br /> R <br /> Insurer 1�itV �1� SP Clb W, Work Comp 1 00 001 800 <br /> QICC Technician's Certification Number a� '�' - tit Expiration Date H a00 <br /> T <br /> Q <br /> R ICC Installer's Certification Number 4" 44 — )AExpiration Date I .Doo <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved Approved with conditions ❑Disapproved <br /> L (S Attachment With Conditions) <br /> 3�Z 3" 68 <br /> N Plan Reviewers Name Dater_ <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 PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 1 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" <br /> Applicants Signature TR140•& Date 1 Vv <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 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 TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br />