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0 <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 APPROVALDATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ?UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#,eoy �jy y+3�.yy/ <br /> � Facility Name "-? 7 --*©2—! --3 Phone# <br /> � <br /> Address ��?,08 ,oV17-11AI <br /> TCross Street <br /> Y Owner/Operator ? Phone <br /> oContractor NamePhone# <br /> N <br /> T Contractor Address CA Lic# pgo Classes <br /> A Insurer Work Comp# <br /> 458 <br /> T ICC Technician's Certification Number 6-94W-0/.- eI77 Expiration Date <br /> RICC Installer's Certification Number — Expiration Date :11—�- C� <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T 6.FA5' 6�11[11c- <br /> - <br /> N l� 97 z4y/ o <br /> K l0emswkw<5<.5- <br /> P <br /> P ❑Approved �pproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date Z <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 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 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title to <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 billing by signature and date below. <br /> NAME /� - .t�, a.� / TITLE �i��/� �/� '+PHOO�NE# <br /> ADDRESS 00�� �s //d?d/f/�iC �!1y zg�- guu. C/S/E' �1y 9D(OZ/ <br /> SIGNATURE 5 �.� <br /> EH230038(revised 12/31/07) <br /> 1 <br />