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N � � <br /> E VIRONM NTAL HEALTH DE RTME�kW E <br /> SAN JOAQUIN COUNTY DE <br /> C 0 VEDD <br /> 304 East Weber Avenue,Third Floor, Stockton,California 95202EnIV/R 46 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 PE;g�j TI E T NEqtrH <br /> R✓1�A <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERW <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT DIPPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# nA, <br /> A <br /> Facility Name M4,10,04jV Phone# - 3- <br /> 1 Address 31 Lj <br /> I Cross Street <br /> T <br /> Y Owner/Operator LL4 Wi <br /> Phone# <br /> o Contractor Name 06`p vw, Phone# 3707 S&93 <br /> N <br /> T Contractor Address 7 CA Lie# Class <br /> I1� <br /> A Insurer Work Comp# 1 1`�g$g <br /> T <br /> T ICC Technician's Certification Number Expiration Date <br /> 0 <br /> R ICC Installer's Certification Number �lS,��flTv (/Z 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 —!Approved Approved with conditions ❑Disapproved <br /> L / (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name v, Date Id 14Q Q <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." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR CH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." / <br /> Applicants Sign Title[-�`� Date <br /> BILLING INFORMATION: <br /> Indicate sponsible 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 8/8/06) <br /> 1 <br />