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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 /> A EPA Site# C_AR (:))UD j,,4D blo Project Contact&Telephone# �dS 51 �- <br /> C Facility Name , I p f ` QUrw io b Phone# 61 3�9 3 a`f <br /> I Address 4 8 Q-e� ��e n � 2 �C� 953 U f a <br /> L '/ <br /> I Cross Street r- Sacfu nnC n 6 �d <br /> T <br /> Y Owner/Operator ��� �U m r� j�n Phone# <br /> C Contractor Name r o►�Q, f U �� h Phone# o9 tc,�,30_rte-1.1 1 <br /> T Contractor Addresslen Z)i mQS CA Lic# 19- gj5j class gZ <br /> A Insurer <br /> If <br /> nd Work Comp# I57�j� ac��5 <br /> cICC Technician's Certification Number <br /> T Expiration Date <br /> R ICC Installer's Certification Number �� <br /> - � � Expiration Date 1 5 app <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T rn n 60-(1 <br /> N 1 a et r n (,Q <br /> K <br /> P ❑Approved Approved with conditions ❑Disapproved <br /> L (See Attachment With 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 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 <br /> �WORK FOR <br /> � W�HIICH THIS FERMI IS ISSUED,I S ALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." �__)_l�.c�l_-F�-��" � <br /> Applicants Signatu Title Date J <br /> BILLING INF ATION: <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 fnr the billing by signature fannd dat below. /� <br /> NAME l m D Q Z�r0. 1�n TITLE ►7L F7h 111. � - PHONE# I c)w �5Y <br /> ADDRESS90S FbfCkU C�Iej /y Q�Lc(,�k e,+ 9/,3D <br /> SIGNATURES <?-5 � <br /> EH230038(revised 8/8/06) <br /> 1 <br />