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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 9.5202 <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 /> .._;TANK RETROFIT ING REPAIRIRETROFI7 11UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A IWI B12 <br /> C Facility Name Vert Phone# l <br /> IL Address r <br /> rtle <br /> I Cross Street <br /> T �[Cf d <br /> Y Owner/Operator I Z�n Phone# <br /> C Contractor Name- LJ Phone# j -86 <br /> T Contractor Address P CA l_ic# -b Y75- Class + �4 2- <br /> R Insurer v 11 Worl<Comp# (�q8hy q666 <br /> C ICC Technician's Certification Number Ex (ration Date JQ727 'r7 <br /> Q ICC Installer's Certification Number f Expiration [late <br /> R 2 :29-07 <br /> Tank iD# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T wo r 4 <br /> A <br /> N <br /> K <br /> P Approved --Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name fM Date---�110G <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 SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMA E OF THF-WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicants Signature Tide Cz .O Date �� <br /> BILLING INFORMATION—.0 <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 rr �(��ink r PHONE# f,i f7`J 66-00621{� <br /> ADDRESS � �[� YY]P1 At1_Caup, Wotio) A. 1CJ>Jr -- <br /> SIGNATURES <br /> EH230038(revised 813107) <br /> 1 <br />