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NOV-28-2012 17:31 From: 2098254549 To:4683433 Paee:2�11 <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 ISD DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW. <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIRIRETROFIT )ttou) TARTIEVR UPGRAID <br /> F EPA Site# Projed Corttad&Telephone# <br /> CFacility Name44 of C JJ Phone# O <br /> � <br /> Address () <br /> I Cross Street <br /> xv thmer/Operato CQ Phone# <br /> !! C Contractor Name P Phone#ate �) <br /> N Contractor Address P l U - CA Lic# r - �3 S— Class <br /> T <br /> R <br /> A Insurer S k.g.^ Work Comp#/ZPK(.7Ct96 <br /> T ICC Technician's Name g .�� FxpiraUon pate cj sZ0 --1.3 <br /> D <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date U$T <br /> eT P"w P.sl leek fte ,,UM Irz,MJ Installed <br /> F T L670 K= <br /> O N - s4a <br /> rc 0, — <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See A1,tachment Wir Conditions) <br /> N Plan Reviewers Name q� i1jQ -", CZ( c-e l nDate <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATION3 OF SAN <br /> JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THEK FOR WHICH THIS PERMIT ISI ED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> RIDER'S COMPENSATION OF CALIFORNIA' CON OR5 HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMAN O THE WORK FO RMR IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WOR R'S COM NSATION LAWS <br /> OF CALIFORNIA' <br /> yCAPP5CR&s 6 AA XTitle ` Dale <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 admowted a this <br /> respo the billing by signature date bel J <br /> X NAME�i'Gf IIJCPO` L�.y. +�/^I� _ (dC_•L//�^''�� L PHONE# <br /> ADDRESS 70+J C7 �S 4, } t-w+T Y1/`n {�G/K ��� q :23 <br /> SIGNATURE DATE <br /> EHZt =(revised MIM 1) <br /> 2 <br />