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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 />WANK RETROFIT (PING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # -f y --0 ? <br />A <br />C <br />Facility Name , ,� L, <br />��"` 300 Phone # 9 A14 3.14 d <br />1 <br />Address C O L 4i <br />"W gb, <br />ICross <br />T <br />Street <br />Y <br />Owner/Operator(. <br />"M"AcpZPhone <br /># 04W dek— <br />C Contractor <br />Name /�� 0 ,v Q,J <br />�������,¢.L e p,vjT <br />Phone # ap e-vp7 ;, <br />T <br />Contractor Address , O, 86k <br />3 &P C6033CA <br />Lic # s"/3 Class <br />R <br />A <br />Insurer <br />Work Comp # <br />TICC <br />Technician's Certification Number <br />5-30 7— <br />Expiration Date <br />RICC <br />Installer's Certification Number <br />T3 dr..0 <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />7 U r <br />(*-s <br />/ <br />A <br />N <br />K <br />P <br />E]Approvq d <br />Approved with conditions ❑Disapproved <br />L <br />A <br />(Se Attachment With Conditions) <br />N <br />Plan Reviewers Name 1k& <br />Date q(tyl,� <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />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 <br />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: "I CERTIFY <br />THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature <br />p <br />Title At5j�l 044-1/— Date <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 />ADDRESS <br />SIGNATU <br />EH230038 (revised 12/31/07) <br />TITLE PHONE # <br />1 <br />