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ENVIRONMENTAL HEALTH DEPARTMENT, <br /> D� <br /> SAN JOAQUIN COUNTY L - ,� 2� <br /> 600 East Main Street,Stockton,California 95202 ou 2 j 2008 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> FF ViRQNENT ijEi;LTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR Pl ?Q, 6I ffi�RMIT <br /> THIS PERMIT EXPIRES 980 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> I—I <br /> LTANK RETROFIT PIPING REPAIRIRETROFIT %UDC REPAIR(RETROFrr COLD ST\ART/EVR UPGRADE <br /> E <br /> Project Contact&Telephone#b k4 - 4-331- %\1,6 <br /> �" 1 Phone# a <br /> Phone# aoq-C{,(g - 3S <br /> u <br /> D Contractor Name W Phone* l(o - 3-( 3- \\U6 <br /> 0 <br /> N Contractor Address CA Lic# Class <br /> T oo Co... �- <br /> R Insurer Work Comp# <br /> A <br /> T ICC Technician's Certification Number S3p1 $(p -UZ Expiration Date <br /> RICC installer's Certification Number Expiration Date <br /> Chemicals Stored Date UST installed <br /> OTanklD# fiTank Currently/PreviouslyTA �k <br /> K <br /> P EApproved 29Approved with conditions ODisapproved <br /> L ^�rn o i4(See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name At-5;� Date N <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 /> WORKERS COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I 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 /> ate <br /> Appli=nts Signature TNe D <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 acknowle(jge this <br /> respon ibility for the billing by signature and data below. <br /> NAMEL �♦tip ��QJ1G1� TITLE `OYw�IJ�\t9A'PHONE# \lo)b�tb <br /> ADDRESS C'� �OAX �b7-S� �i�C� cit, ,s kA\ <br /> SIGNATURE_ . <br /> EH230038(revised 12131/07) <br />