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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 /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name (�OU 606 fito.61Z Phone# 0-F o 448_ -f-T, Q <br /> Address <br /> TCross Street <br /> Y Owner/Operator Cts /�.' Phone <br /> o Contractor Name Phone# <br /> N Contractor Address )c ( ' gS f�8 '� - <br /> T �r� CA Lic# Class <br /> R <br /> A Insurer Work Comp#I 7307SR©/ <br /> T ICC Technician's Certification Number (�3 j/ Expiration Date '7 <br /> R ICC Installer's Certification Number /4 Expiration Date ! /ol <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑ApprovedXAchment <br /> pproved with conditions []Disapproved <br /> L With Conditions) <br /> A <br /> N Plan Reviewers Name-,Z,_ L c _� Date <br /> APPLICANT MUST PERFORM ALL WORK IN AC CE 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OFT�EWORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicants Signature Title 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 /> responsibiilliittyy for the bililinn by signature and date below. d,51 <br /> �, ,� �y ` g <br /> NAME ��'/JL 1/�� f TITLE -�'/'�% a'// PHONE#7�6 r��5 <br /> ADDRESS K ( 9S-7(- <br /> f <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />