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00 ' <br /> , 40 <br /> 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 DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT [K <br /> DC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#/�/l�K4c- ?/y <br /> A <br /> G Facility Name 0 0 O 46 0196 Phone# <br /> Address - ��.✓ ���' <br /> T Cross Street /io"-oy <br /> Y Owner/Operator Phone# <br /> C Contractor Name Phone# <br /> o Y Ale / g e9 e-2 <br /> T Contractor Address Zj CA Lic# jos11s Class <br /> R Insurer �" <br /> A j�/ Work Comp# <br /> c ICC Technician's Certification Number Expiration Date <br /> T S3�viC�/-UT p' g �'�6 n <br /> Q ' <br /> ICC Installers Certification Number <br /> R S//Sr''f'j /1 Expiration Date 0—/Z9;ee) <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> 0g=, <br /> K <br /> P ❑Approved LA"Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name OM IA,41W i"mow'^ Date 3 y 10 <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 /> Applicants Signatur itle / l� C? 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 <br /> for the billing by signature and date below. <br /> NAME � 4�il/y6;; 111 TITLE ;W K� /4//S�/ �H0NE# <br /> ADDRESS /ZZ (X /�Jly Z-1/ <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />