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03/26/2009 THU 7: 53 FAX 2094683433 SJC EHD 2003/008 <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 APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> P EPA Site# Project Contact&Telephone# <br /> A U <br /> C Facility NametCe"p Phone# <br /> LAddress Q <br /> ICross Street <br /> T A� � <br /> Y Owner/Operator i A Zj7j��I t:i 9 V Phone# 2og-cep is—'5,951 <br /> C Contractor Name s � C', YD r1 Lkvxc wc-ZZ z7� O <br /> O Phone# <br /> T Contractor Address �'7 i�`�, �� CA Lic#�LZ cis— Class <br /> A Insurer �?l lti� Work Comp#� 7-27 -o( <br /> T ICC Technician's Name it er, L j 44v_> Expiration Date D <br /> DICC Installer's Name k�i Expiration Date <br /> R 0 <br /> Tank system work area Tank Size Chemicals Stored Currents Date UST <br /> (La 87 piping swnp,s1 teak aeledw,UDC In,dc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P 1_� Apoved Approved With conditions �_� Disapproved <br /> L (Se ttachment With Conditions) <br /> A � �N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK INVACCORDANCE 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 <br /> TO WORKER'S COMP TION LAWS OF CALIF A." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT#N THE PEI <br /> E MAN E OF THE WORK F <br /> OF CALIFORN WHfCH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> A pNCaM's S natu Title S Date Z d <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be tilled 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 thebilling by`signature and date below. <br /> NAME A ftLk A76C 0 iCLn TITLE___ s�6.4er PHONE <br /> ADDRESS r 6= S kC,.f'"W,(1'l <br /> SIGNATURE DATE <br /> EH230038(revised 02120109) <br /> S <br />