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s � r <br />ENVIRONMENTAL HEALTH DEPARTMtWf-.-- <br />SAN JOAQUIN COUNTY MAR 0 6 2007 <br />304 East Weber Avenue, Third Floor, Stockton, California 95202°I�,()�3y°�r i/,.w <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 '{` {{� P'�j _: <br />��tTr°INI`t } iY41dD�'' <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 RFTRr1PIT XPIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # wtO,41 <br />� <br />Facility Name ' wC C "j <br />Phone # -+ <br />I <br />L <br />Address t &lr (! to c& <br />TCross <br />Street T — <br />Y <br />Owner/Operator cmoct-RLM(m <br />Phone # ( '' <br />C <br />O <br />Contractor Name A b T'Ld m <br />Phone # ° - <br />T <br />Contractor Address <br />CA Lic# t Class C161 <br />RInsurer <br />A <br />viY� Work C omp # <br />TICC <br />Technician's Certification Number ` Expiration Date s <br />R <br />ICC Installer's Certification Number (' ' Expiration Date Q, <br />Tank ID # Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />❑Approved %Approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name a Date l� <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 />Aoolicants Sianature itle Ch 1AI& U& 10� Date R s <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 c E;L TITLE CQA44dua <br />a PHONE # <br />f <br />ADDRESS e � b)loa CA <br />� <br />SIGNATURE ILI <br />EH230038 (revised 8/8/06) <br />1 <br />