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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 REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# M C�ICh �{�gl3-bt)3 <br /> A Phone# �q- ` 1 (?- <br /> C Facility Name 155 � � 0.2,[.; ( :30 `jja.., <br /> � Address e (�tAlQL1 <br /> TCross Street <br /> Y Owner/Operator Tlesc*_C Phone# a2J3_ $ - �Qq <br /> o Contractor Name �� ��5'- {zcH S S{"� _J LyL, Phone# <br /> N Contractor Address (Q 6 CA Lic# $ 9,It Class C.b1NO 4Z <br /> T lY t Vi�l /Z V�. T I l <br /> A Insurers L,L(Lf, Work Comp# <br /> Sa��t3 <br /> T ICC Technician's Certification Number S�(E( �S4- U T S S�Sb0- l�( Expiration Date L 1 t <br /> R <br /> R ICC 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 ❑Approved Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A 6 o� <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 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." 1, 'y`� � /� (c' <br /> Applicants Signature l.ccLL' v• v ll 1=(LLZ (L�$"' Title �� `' riCom/ Date �l <br /> BILLING IN 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 <br /> ,,by``signature and date below. <br /> NAME e-'�Cl-t-6LA-41 Wk L'KL-l4_. TITLE i thL -P c� PHONE# -IM\ ��A <br /> ADDRESS Qv►vi(�l Ace. -Sak"._ l J_11 <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />