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NV[R�tVlit[ENTi4L hEALTH:'II; EPARTMENT <br />SAN JOAQU0 COm�. <br />304.East WeberAvenue, Third Floor, Stockfoh, California 95202 <br />Telephone: (209).46$ 3.420 . Eai�: (209).468 3433. . <br />APPLICATION .FOR UNDERGROUND. STOIAGh. TANKRETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMITTYPEBELOW. <br />: <br />LJTANK RETROFIT . .. PIPING REPAIRIRETROFrr DUDC REPAIR/RETROFIT <br />F.., fEPA Site #: Project !✓OntBC(& Telephone # <br />A, <br />C Faality Name : Phone # <br />' L Address '� t:V�, .. - • <br />•t T. Cross Street <br />Y Owner/Operator ' Phone <br />_Conkahtor Name''. A, <br />r Contractor Address: :: :::: .; :j CA Lic # •� Class <br />R . <br />. A Insurer' . ; ... - •,>: • . - INt►rk Comp # • _ <br />c ; <br />T. Expiration Date <br />ICC Techniaan's Certification. Number <br />a <br />. •R IGC installer's Certification'Number ' <br />Expiration Rate . <br />�i <br />Tank ID # ... Tan[c S¢e . Chemicals'Sfored - Date IiST Insfalled <br />currenffj /Previously <br />'> <br />•N.} <br />.K•. ?a <br />P DApproved �pprovedmith conditions' Disapproved <br />A: <br />(See ment With Conditions) <br />N Plan -Reviewers Name Date ��/Z <br />.4pf'tJCA 11IUS I PERFORM! ALL NiOTi1C IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS AND RULES AND REGf1LAT10NS.OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTId DEPARTMENT OWNER OR LIGENSEb AGENT'S. SIGNATURE CtE TIRESTHE FOLLOWING:."I CERTIFY THAT IN <br />THE.PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHAH N0T EMPL-OYANY PERSOIJ IN SUCH A MANNERAS TO BECOME SUBJECT TO <br />WOIiICERS .COMP."ADON LAWS.OF CALIFORNIA." CONTRACTOR'S HIRING OR.SUBCONTRACTING,SIGNATURE CERTIFIES THE FOLLOWING 9 CERTIFY .: <br />rF3ATJN.I]1E.81 Q 71MCE OF..THE WORK.FOR WHICH THIS 1?ERMfT IS ISSUED -1 SHALL EMPLOY PERSONS SUBJF-CT TO WORKERS 1COMPENSkli LAWS - <br />-OFGAL-iFC3RNIA' — — -- - <br />;..�:.Apq�GcantsSignatUae'' '_ -:=Itla-- 4i. Dale <br />:,fir,.:•: -BfI�N. NG'I, FORMATION <br />Ins u ate the responsibly party o be billed #or. addrbOnal #i@ staff Ime expended begoM �ermit=payriient covdrage pei talk If' <br />?arly-desi9riat bofow s difieienf ul rtne -pe apj31[t it,. s g pro owner,: a mus ac o ge this : --- <br />responslbllity�f�orthe billing by -signature and•date below.. ' <br />uu ; <br />tVA1�lE TlTiT1E`a,► PHONE #_Z19_i�;�—�l�r ol► <br />ADQR�s 25-:�.1�� i1�Ac► nly�; 5'It�'� . Q73 <br />,4 <br />SIGNATURE. <br />EHZ0038 (revised W8106) <br />