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• ' _ _ - __ .�..�" , ,-,vim VJ! VV. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209) 468-3420 rax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES i80 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> n EI <br /> OCOLO START/EVR UPGRADE <br /> TANK RETROFIT LIFIPING REPAIR/RETROR7 IJUDC REPAIR/RETROFIT <br /> F EPA Site# (®p ZOO(? 1�Q Project Contact&Telephone# fl J1 SL <br /> C Facility Name l 6-1' 'FVC)6 A QO uC�� Phone�#7 i 333 1Q3� <br /> I Address j22� iR.a• <br /> I Cross Street �M,`tlS <br /> Y OwnerlOperator as �. Phone# <br /> C Contractor Name V�G� & �S ►n5 C iv►� Vt� Phone# moo►•� 1—Ct31 <br /> N Contractor Address Pb t Li 0� X I O q SLS( 1 GA Lie# �j Class i°r �t(7 I-I a4Z <br /> T Work Comp#2, 7_-� 0 -O S/ <br /> R <br /> A Insurer �,y�(� <br /> o <br /> T ICC Technician's Certification Number Expiration Date l� l <br /> o ICC Installer's Certification Number Expiration Date QGj <br /> R <br /> Tank Chemicals Stored Date UST Installed <br /> Tank ID# Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A � <br /> NI Plan Reviewers Name Date <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 AC 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 PERFORMANC F THE WORK FOR WHICH THIS PERMIT IS ISSUED.,I$HALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPE ATION►AWS <br /> OF CALIFORNIA' r <br /> ApPricant;,Slgnalvrc <br /> �.-� Title Date <br /> BILLING I FORMATION: <br /> Indicate the responsible party to be billed for additional EHO 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 /> Ezq <br /> ADDRESS I ? U)� T \ t C) <br /> SIGNATURE <br /> EH23003°(revised 12/31!07) <br /> .l, <br />