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ENVIRONORTAL HEALTH d PARTIVIENT <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 OPIPING REPAIR/RETROFIT <br /> UDC REPAIRlRETROFIT UCOLD START/EVR UPGRADE <br /> A EPA Site# Project Contact&Telephone# <br /> C Facility NamehAll <br /> ^� i f !�J <br /> 1 �1 S e lg PW,4,7 ,4 5)c Phone# c; a 1 <br /> ( Address C—Zz' j fe z. 5 f"s <br /> T Cross Street <br /> Y Owner/Operator fZrJ � _ <br /> -� e� Phone# <br /> C Contractor Name " ' .-�' <br /> Nzn �-� ! Phone# ,� _ �,� f <br /> T Contractor Address e e���� <br /> R �.-- < c, CA Lic# 5/a _- Class <br /> A Insurer <br /> Ce� fir '�' Work Comp# x r ,-- <br /> T ICC Technician's Certification Numberoz e <br /> 0 S 3 � J`-' Expiration Date 6=,r' <br /> R ICC installer's Certification Number " <br /> �� 5 Q9! 3 6-' ( Expiration Date <br /> Tank ID# Tank Size Chemicais Stored <br /> f Currently/Previously Date UST Installed <br /> N Al <br /> f <br /> P ❑Approved ,-,/ <br /> L L"1Approved with conditions ❑Disapproved <br /> A (See Attachment With Conditions) <br /> N <br /> Plan Reviewers Name_ mA I �,c� <br /> Date <br /> APPLICANT MUST PERFORM ALL O K IN ACCORD CE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, <br /> OF TH <br /> THE PERFORMANCE E OR IC AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, TH NM A HEALT E MENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING_ "I CERTIFY THAT IN <br /> A I PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSTIO OFC LIF N ." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "i CERTIFY <br /> THAT IN THE PERFORMA OF O ICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature / <br /> BILLING INFO ' ATIO Date <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 <br /> responsibili r the biilingSignature and date belowe� lt applicant, e.g. property owner, the party must acknowledge this <br /> NAME ! C <br /> TITLE <br /> PHONE# --- <br /> ADDRESS L?mss" ! t ✓l G--C�i Y <br /> SIGNATURE <br /> EH230038(revised 12/31/0 <br /> I <br />