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Mar 28 08 10:02a Sandra Barnhart 2098458586 p.4 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East!,lain 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 /> "HIS PERMIT EXPIRES 189 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW <br /> TANK RETROFIT LPIPING REPAIR/RETROFIT CUDC REPAIR/RETROFIT COLD START,EVR UPGRADE <br /> F EPA Site# <br /> A Project Contact&Telephone# <br /> Facility Name Ala!n S Tr fa A 0 5 Phone# aU q, <br /> L Address j <br /> I Cross Street <br /> T <br /> Y Owner/OperatorS.S e. �� Ph 7� <br /> �� <br /> c U a�� as-� <br /> o Contractor Namej �-�- <br /> 7 Contractor Address r Phone# 0 0 q, <br /> R L!S` <br /> S� r�('a U CALic# �'g3_?b Class <br /> Insurer <br /> C A C P11 V'I K0 n wt t41VfU Work Comp# v <br /> 0 ICC Technician's Certification Number <br /> rJ a J�(� l5f- Expiration Date <br /> R ICC Installer's Certification Number rJ�S�5 y0 _U Expiration Date <br /> Tank ID# Tank Size Chemicals Stored bate UST Installed <br /> Cu rrenttylPrevio usly <br /> T r3 I0100 0 <br /> Caa�cjl�,t� <br /> A <br /> N <br /> K <br /> P L!Approved Approved with conditions UDisapproved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> Date 4111/q <br /> APPLICANT MUST PER,FORM 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 TD <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACT:NG SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE CF THE WORK F„OR WHISH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION,LAWS <br /> OF CALIFORNIA' { / Nin �f 7 Q� <br /> Applicants Signature I -lel �� � Title /L <br /> Date <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 by signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 12131107) <br /> 1 <br />