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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 /> ❑ TANK RETROFIT PIPING REPAIR/RETROFIT El UDC REPAIR/RETROFIT El COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# ltdA.1r. !]2w5 _525-1111f <br /> A <br /> C Facility Name H Ei-4 re HM4-m4p- ione# <br /> I <br /> L Address <br /> T I cross street <br /> Y Owner/Operator #0 EMTE Phone# <br /> c Contractor Name jr <br /> 0 MP1409-WHDERI�11_4 Phone# 1 <br /> N Contractor Address iv,0, Vz 146-] C,;.A* <br /> T CA Lic Class <br /> R <br /> A Insurer W, Work Comp I s r, <br /> C <br /> T ICC Technician's Name J0449 SWTT-21 H Expiration Date <br /> 0 <br /> R ICC Installer's Name 114 Expiration Date 4 /10 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leek detector,UDC 112,eft.) Installed <br /> T <br /> A <br /> K <br /> P El Approved El Approved with conditions El Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <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 AGENTS 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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORIPANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicaff Tide 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 /> NAME­Iljc� —TITLE— PHONE <br /> (-) <br /> ADDRES <br /> S <br /> :7Zq1 <br /> SIGNAT <br /> EH230038(revised 02/20/09) \j <br />