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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN 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 <br /> 11 BELOW <br /> UTANK RETROFIT UPIPING REPAIR/ MORT L uDC REPAIRIRETRORT <br /> F EPA Site# Project Cantacf&Telephone# C (L a r(-1 '' ,i 3� t <br /> A <br /> C Facility Name rAo4--a I qww� <br /> C( Phone'# 5 _ <br /> L Address ` I 3V� ' C, <br /> t Cross Street <br /> T _ <br /> Y Owner/Operator Phone# (� <br /> O Contractor Name l9 �{ t C`` <br /> c ° Phone# <br /> TContra r dress r ` CA Lic# ) Class C Z <br /> A Insurer n ic)r 1a y� Work Comp# n L s(! 1 <br /> G <br /> T ICC Technician's Certification Number Expiration Data . <br /> R ICC linstaWs Certification Number Expiration Data <br /> Tank ID# Tank Size Cu�rreenntly/P Stored <br /> dale UST Instated <br /> T <br /> A <br /> u <br /> K <br /> P UAppraved Approved with conditions UDisapprDved <br /> LSee Attachment Wrftt Conditions) <br /> A <br /> H Plan Reviewers Name ' 11 �. - Data > <br /> APPLIC MIT MLLSr PERFORM At1 VADW LMA At CE_InBTH SAN Ja&O.J@I C aZC Y ORUIc AWrC .,STATE 1AN4S,AN[2 0 9 ES AND-REGLAATIONS:CF SAN <br /> JOACILAN COUNTY,EW RONMENTAL FEAL.TH DEPARTMENT.C 44ER OR LKBSSED AGENT'S SIGNATURE CERTFES THE FOLLOWI1,13: -1 CERTIFY THAT W <br /> THE PERFORMANCE OFTW WORK FCR V"CH THIS PERIAT tS 6%® 1 S!-TALL NOT E UFP ANY PERSON W SLICH A IlAMNER AS TO BECOME SUBJECT TO <br /> WOM(ERS COWU14SATION LAWS OF CALIFORNIA" CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE FEwoRkArrE OF THE wow FOR 0+H1S MrT S EMPLoK'P SUBJECT TO WORKER'S COWSATION LAWS <br /> CF CALIFORNIA- <br /> .�L C <br /> Appficarts <br /> BIWNG t RMATION: <br /> indicate the responsible party to be billed for additional EHD staff fine expended beyond permit payment coverage per tank tf <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibilfty for the billing by signature and date below- <br /> NAME I J ' l / TITLE PHONE I <br /> C' <br /> ADDRESS. V �'J'ffilk <br /> SIGNATURE <br /> EH230038(revised 8/aMG) <br /> 1 <br />