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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 ILyPIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# i C u Q S L <br /> A q T69 916 <br /> O Facility Name t L A t L41Z } Phone# S3A _ Is S- <br /> L <br /> L Address 3 3 p a C,(/4_T-t2 0 d -� <br /> Cross Street <br /> T REP 0 r>r-r AVE . <br /> Y Owner/Operator NS L L A, O (L CID . L L C Phone# 5-30 - gds- <br /> c Contractor Name Phone# <br /> o wA �ra�c 1✓�( C i FtEI2I It(11 c , 9(6 _ -343 - /IT-1— <br /> N Contractor Address <br /> T (3oK rOzs LL) 9r6c, CALic# 6�}Z3 � Class <br /> A,B, 14,4 2__ <br /> AInsurer S T-A-tE <br /> F v" Work Comp# :� l3 0 00Q 2 30 6 <br /> T ICC Technician's Certification Number <br /> $ EE A-7-7-dcN-r,4 Expiration Date <br /> R ICC Installer's Certification Number <br /> S F-E A•Y-T A-c bh" Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T 0 ( !O /Z. ("A-S - S 4- <br /> A O 2- <br /> N <br /> bt e-S FJ 1j,L <br /> P DApproved Approved with conditions ❑Disapproved <br /> L <br /> A / (See Attachment With Conditions) <br /> N Plan Reviewers Name () Date I'U <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 LAW OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF HE WORK FOR WHI H THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title C 0 kL-7-(Z AtA Q h Date 0 ® 6 <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 TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br /> 1 <br />