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ENVIRONMFIWTAL HEALTH DEF�RTMENT <br />AN 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 ni lnrr DMDAM <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />I <br />Facility Name1 " Phone #afi _ <br />L <br />Address t,. �Eo QVC fflckoia M., CQ <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator tan <br />Phone # 2 <br />`-1 <br />oContractor <br />Name ; ' <br />Phone # <br />INContractor <br />T <br />Address \ . STIYC.rSZ>(1 <br />CA Lic # &(0(06 Class <br />RInsurer <br />A <br />Work Comp # _O <br />T <br />T <br />ICC Technicians Certification Number <br />' <br />Expiration Date <br />QICC <br />R <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />L <br />❑Approved &Pproved with conditions []Disapproved <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name //Y% Date ( I <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 SIC -NATURE CERTIFIEF.. THE FOLLOWING: `I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLO Y' ANY PERSON IN SUCH A MANNERAS TO BECOME SUBJECT TO <br />WORKER'S :COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY F ERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />/ rr <br />Applicants Signature�_� Title_�j.Q n it� No 4 k l - Date Q 1 ALA , A l I <br />BILLING INFORMATION: <br />Indicate .the responsible party to be billed for additions,, EHD staff -time expended beyuna •permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property oriner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME. T3TL6_gV� %JL�_: PHONE#_'qi&t `U3 <br />ADDRr'SS <br />SIGNATURE �1 i.Yll1 <br />EH230038 (revised 8/8/06) <br />