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JAN-16-2009 15:55 Seruice Station Systems 408 938 8888 P.03 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, 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 180 DAYS FROM THE APPROVAL <br /> !DATE, INDICATE PERMIT TYPE BELOW; <br /> i_ITANK RETROFIT G IPING REPAIR/RETROFIT L.!UDC REPAIRIRETROFIT 'L—COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name Phone# _ �(o _ 3 <br /> L Address <br /> i <br /> TCross Street jr,, <br /> Y Owner/Operator t Phone# SS-n7 <br /> C Contractor Name S S Phone# 40 k- A�— <br /> T Contractor AddressCA tic# <br /> t,{r <br /> R Class C1Q11 AO Z <br /> A Insurer Work Comp#.3 Iy Lard <br /> cICC Technician's Certum <br /> Certification Number T Sd� �S(oU —U� Expiration Date <br /> R ICC Installer's Certification Number <br /> R �13 3'710 Expiration Date 711,4ho <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 ODisapproved <br /> L <br /> A (See Attachment With Conditions) <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.' CONTRACTORS 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 CAUFORNIA.' L� beA `� / �U <br /> Applicants SIgnalwe .(,LIA Tltle ..� Date `) <br /> BILLING I ORMATION: <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 Belo ;c <br /> c�.heho-l��F �f <br /> NAME j CC 1,I a- TITLE (Z. PHONE i1 4Uk- 7 c <br /> 3&- 7)j <br /> ADDRESS �o � (�,�1 i.�o' f <br /> SIGNATURE�7(�0 � A I <br /> EH23DO38(revised 12/31/07) <br /> z <br />