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JUN-29-2007 10:48 F—vice Station Systems 408 938 8888 P.03 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor, Stockton, California 95202 <br /> Telephone, (209)468-3420 rax: (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 /> �I,,,TANK R7 TAOFIT `-]PIPING REPAIWRETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# � Project Contact&Telephone# <br /> A <br /> Facility Name Oskk cI-5 G Phone#�2L```?-- <br /> IAddress �..,.�.— _. �-.....-•�._,�............_.....____ _. _-- <br /> TCross Street <br /> Y Own(WOperator -4 Phone ft ;ZS,3.. °f�p ." �aot <br /> wC Contractor Name `j,��c.Z�._ tT�&.C�t t S'( vlt� L: I Phone# <br /> T Contractor Address CA Lic# Class C'. l NO >{�� <br /> A vL <br /> Work Comp# <br /> 0 <br /> Insurer <br /> �� � �f a••Y?� � �._......�•a�..::�l�J.�,c,` k� rJ �c.Z. <br /> T IO n_,ti 4,-.. 1.) � ti�3 \''�'1-J}.. f F(- Expiration Date 6 17 1 oa f1(1'7 <br /> tt <br /> ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored i Date LIST Installed <br /> Currently!Previously <br /> A <br /> N -- <br /> K <br /> p ❑ApprovedApproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A ``� <br /> N Plan Reviewers Name �r.-Y .,, __Date l C/ <br /> APPLICANT MUST PERFORM ALI.WORK IN ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OP SAN <br /> JOAWNI COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT,OWNER Ok LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWENG' "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 SUOJECT To <br /> WORKER'S COMPENSATION LAN/$ OF GALIpORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANCE;CF TWE WORK FOR WHICH TrnS PERMIT 1S ISSUED,I SHALL EMPLOY PFriSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> (" iL.. 4LL. ; . Ut- Title .�:. , L. L l;t�'C�C{'i� Owe- - laj <br /> Applitancg Signature "' �, � 4�; ` _ _ <br /> BILLING IN ORMATION, <br /> Indicate the responsible party to be billed for additional EMD 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 �k LG�'C'G(h-1�r ���,�"L�L(,(iidL..f.-1 TITLE!_'"-." <br /> ADDRESS EGAy U�� ibi V. A0Z Q�lt V[.�a�'r 6A W(� <br /> d <br /> SIGNATURE <br /> EHP30038(revised BIB108) <br /> 1 <br />