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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 DAVE. INDICATE PERMIT TYPE BELOW: <br /> `IZITANK RETROFIT OPIPING REPAIR/RETROFIT IUDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# tAQ W-C t .I/LkatA Mpg_ ;LQ-Qb3 <br /> � Facility Name USA Phone# a 0 9- 7J <br /> 1 Address _')4Lt K-ej6(Le_VV_Cj," LjACA <br /> TCross-Street . <br /> Y Owner/Operator Tes �-b Phone# a C 3-4 4- Y%69 * <br /> o Contractor Name S-+"&4 -S-qjteaL5 Tjk� Phone# LFbB-9-B- &03 9 <br /> T Contractor Address (D 30 C_)U�uK due CA RSI if 90 94 -8,Clel �ctp!{ Z <br /> �, CA Lic# Class <br /> A Insurer U�CCc�e e Work Comp#-S% QMo2 d 63(o0g <br /> TICC Technician's Certification Number Ur Expiration Date (0 1 aha <br /> RICC 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 CApproved proved with conditions ❑Disapproved <br /> L See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL W4K 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 WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants SignatureV L. v Tille �l(ACLC� �T���C� Oate a�� <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 bysignature and date below. <br /> NAME R�t�N. Wk. t� Vka_yj —TITLE eb�j ml,&Z C-A U`i `1'%&W PHONE# <br /> DA <br /> ADDRESS `��U OuZLkvt , Au Q. r ALL �O� <br /> SIGNATURE (tA QA - <br /> EH230038(revised 12/31/07) <br /> 1 <br />