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• <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY HEMMED <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 MAR 3 1 2008 H <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPIFqn T 9' <br /> 1 <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> LTANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# c'q <br /> � Facility Name AP—co 0900 Phone# o Cl N L65150 <br /> � Address /a,�j p IV. U)IIS Ck <br /> T <br /> Cross Street <br /> Y Owner/Operator &I-0 Phone# <br /> o Contractor Name 7�i0A1 AA10L06 G Phone# <br /> T Contractor Address /7' E p CA Lic# Class <br /> R Insurer Work Comp#.3 q J,LJ7 q 9 <br /> A <br /> T ICC Technician's Certificatio Number p c. �•/� S-p1 Expiration Date —5_ 0 <br /> 0 <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P LIApproved proved with conditions 1.._IDisapproved <br /> L (S e A achment With Conditions) <br /> A <br /> N Plan Reviewers Nam Date U <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." CONTE -,TOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM CE OF THE WORK FOR WHICH THI, ERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." p� <br /> Applicants Signature Title Date O <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 8/3/07) <br /> 1 <br />