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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 /> I I THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> LJTANK RETROFIT UPIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> G Facility Name Phone# a 7�r7 <br /> IAddress <br /> L <br /> ICross Street <br /> T <br /> Y Owner/Operator �' Phone# arc/_ Ota <br /> 0Contractor Name <br /> o � Il) / /A1C. Phone# / - 0705— $-3 <br /> N <br /> T Contractor Address P a� vZg (.cS0,.0A T7' CA Lic# '���9�g Class - a <br /> A Insurer 5. I n / S� Work Comp# 000 '7� �v�0 <br /> TICC Technician's Certification Number <br /> T 5 )•S 7ci07 Expiration Date 6--/ -a� <br /> R ICC Installer's Certification Number <br /> 14 0 Expiration Date I-/S <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 <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." <br /> ApplicantsSignature / 44_,/ Title•44Date 3— 2,6/7 <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 billingby signature and date below. I�V /� <br /> NAME / jam/dL� i� '�rll.Z) TITLE r-GTT�010r'� PHONE T11e <br /> ADDRESS �� - d;Q(j5yynCq 95_ 76,-7 <br /> SIGNATURE <br /> _Z� 61� <br /> EH230038(revised 8/8/06) <br /> 1 <br />