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• ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> []TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone#10&hrr ,5 e'f)1/,4//.h ;7,*-3 33 6� <br /> A <br /> O Facility Name m L)h j C r2U l Co_ cP ,,kli711- Phone#,)eel 33 3 - 6 Jct <br /> IAddress <br /> L 33 i 5. t� m (,w <br /> T Cross Street v►i,4 i1 (—,,4,12— <br /> Y <br /> „4„, —Y Owner/Operator `Dj Phone# a07 ',3.3,3— 7Q (,a <br /> C Contractor Name P �� v,,,� ✓ZU �_ Phone# 916 <br /> 0 <br /> T Contractor Address 7c� —7�,� Sal ,rjK� 141 /} Lic# 8i/�/7� Class , 1j.4 Z <br /> A Insurer S�,4 � �v�c-4Work Comp# 8$ <br /> cICC Technician's Certification Number �a S v(� _(� Expiration Date /5/ j�-7 <br /> T <br /> 0 <br /> R ICC Installer's Certification Number 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 WApproved with conditions []Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers NameDate lu�ti10 0� <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 /> 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 WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Sign re' 291_ ' Date 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 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 />