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1 r <br /> 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 OPIPING REPAIR/RETROFIT A ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# j <br /> A <br /> C Facility Name -0"5�vv ' Phone# d o <br /> Address3&19r 9 <br /> TCross Street — <br /> Y Owner/Operator Phone# <br /> oContractor Name Phone# <br /> T Contractor Add ess �� " CA Lic# Class C �D NAz <br /> A Insurer ' Work Comp# D6GL�-6/77 D <br /> T ICC Technicia Certification Number Expiration Date <br /> Q ICC Installer's Certification Number Expiration xpiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P p DApprQved Approved with conditions ❑Disapproved i <br /> (See Attachment With Conditions) <br /> A <br /> N Plan Reviewe+s Name Date a' <br /> APPLICANT 61UST PERFORM ALL WORK,IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWNS,AND RULES AND REGui ATIONS OF <br /> ,IOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR Ltc'_NCED AGENrS SIGNATURE CERTIFIES THE FOLLOWING. 11 C r'iR 'H;1' <br /> 'THE r Ef .RMAR' E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL.NOT thPLOY ANY PERSON IN SUCH A MANNERAS TO BECOME SUBJEG' <br /> WORKER'S COMPEN`A' ON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FO'_I.OWING: "I CERgiIr <br /> THAT IN THE PERFGR "ICE t�F T(iE WORK FOR WHICH THIS PERMIT ISI UED,I SHA!I-EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS I <br /> OF CA€I:ORN A <br /> // I <br /> App ..is.,ign2 — Tine _�Of-�l� = <br /> BILLING INFr'FMAT'0N. <br /> Inci;c.at :t•e rF)p nsible party to be billed for additional EHD staff tin',r .xppaded beyond permit payment coverage tx:r tank. Ir <br /> the pafiyd I nated below is different than the permit applicant, e-q_ property owner, the party must acknowledge this <br /> �e n :b+tlt f r nature and date below. <br /> , _— -- TITLE <br /> YONEN1Tlf � /k&ya <br /> SIGNATURE <br /> EH230038(revised 8096) <br /> I <br />