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71 <br /> ,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 ❑PIPING REPAIR/RETROFrr OUDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# tiaC� — v <br /> A <br /> C Facility Name ��Q1 � �}, Phone _ <br /> I Address 1 G '2 <br /> ffL <br /> Cross Street <br /> T — — d`,`J` <br /> Y Owner/Operator ( Phone# 9-12--(� <br /> C <br /> Contractor Name �; ` Phone.# <br /> T Contractor Address '' )M D t S&_%'Cn CA Lie# l�OC�7�q Class LAO *A fi <br /> R Insurer Work Comp#W PL5065 i _® <br /> T ICC Technician's Certification Number Expiration xpiration Date <br /> RICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> IN <br /> K <br /> F EJApproved ­ proved with conditions ❑Disapproved ' <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name — - Date' <br /> APPLICANT MUST PERFORM! 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 AGENTS SIGNATURE CERTIFIES-THE FOLLOWING: "1 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: "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF.THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY FERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." �/1 1 <br /> ffm Low ,�� 'ride T Date <br /> Applicants Signature . <br /> BILLING INFORMATION: I <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 /> ADDRrSS (01511Lnm 0N\1F1 1516S1iL __ Qfr) CJ�5 <br /> SIGNATURE �1 <br /> EH230038(revised 8/8/06) <br />