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ENVIRONMENTAL HEALTH APARTMENT <br /> SAN JOAQUIN COUNT' <br /> 600 East Main Street,Stockton,California 9202 <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 %UDC REPAIR/RETROFrr ❑COLD STARTS UPGRADE <br /> F EPA Site# Project Contact 8 Telephone#-\- <br /> Facility Name Lp" �..r 1 <br /> Phone# oZ - <br /> L Address <br /> I Cross Street <br /> Y Owner/Operator Phone# aoq-9Y9 - 3S <br /> oContractor Name Phone# 00 - Z-1 b` m06 <br /> T Contractor Address 3 00 Lo c... , CA Lic# Class 3 <br /> R Insurer SkWork Comp# <br /> A <br /> D ICC Technician's Certification Number 530-1 $=Stored <br /> Expiration Date -9- O <br /> T <br /> D ICC Installers Certification NumberExpiration Date <br /> R <br /> Tank ID# Tank Sizered Date UST Installed <br /> uslyTA �1.� <br /> K 3 13 k �. <br /> P ❑Approved ❑Approved with Conditions ❑Disapproved <br /> L (See Attachment Wdh Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAb <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES TI1E FOLLOWING: 9 CERTIFY THAT Ib <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 TC <br /> WORKERS COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFI <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAW, <br /> OF CALIFORNIA" <br /> Appfl ceras Signature Title Date . <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 bysignatureand date below. - - <br /> ` <br /> NAME �L\C >,h-P -o 4lG TITLE C0Vv ��` e.a r 1t� 1CC.Y PHONE#����o� <br /> ADDRESS �w- <br /> SIGNATURE�-� F <br /> EH23003B(revised 12/31/0 . <br /> 1 - _ <br />