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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 D TE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT DC REPAIR/RETROFIT XCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> Aiy tJ ►� 5 N {r I L.i_ <br /> C Facility Name j rZO Al 5 1 Phone# _ 2- <br /> I Address 440 W, C k r V/A <br /> TCross Street S. L,P„c v Lw <br /> Y Owner/Operator Jv�' �,� Phone# L S,-Ly e 7 <br /> C Contractor Name .� „ .rAi w r Phone# (,Lt-Z�, <br /> N ContractIL or Address (,�;t Z CA Lic# 7rj" 260 Class HAA Insurer G V, �Z:. - Work Comp# �; , Z <br /> la <br /> etc, <br /> TICC Technicians Certification Number <br /> T ' Expiration Date <br /> QICC Installer's Certification Number Ef <br /> R 7,Z/ •- V Expiration Date Z ZG C� <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved KAchment <br /> proved with conditions ❑Disapproved <br /> L (S With Conditions) <br /> A 72 <br /> N Plan Reviewers Name Date <br /> __/ / ?I h 7 <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." <br /> Applkft3ug�ahry Title � vd N� [- IZ 6eeme <br /> BILLING INFORMATION: <br /> Indicate the responsible parry 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. 7 <br /> NAME Al1�A \(V��h �� 1 TITLE C)t_,; t-�' PHONE# •4bS Zy / <br /> ADDRESS 44 �`�rT� WX!1 <br /> SIGNATURE <br /> EH230038(revised 12/31/07) �` <br /> 1 <br />