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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQU N COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 45202 <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 OATS INDICATE PERMIT TYPE BELOW <br />UTANK RETROFIT UPIPING REPAMETROFTT UDc REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # Cff- <br />CFacility <br />Name ���(� (, �t� <br />6U <br />�P h Phone # - <br />kr ff j <br />1 <br />L <br />Ad(51Mdress o Haa=x <br />tanc) <br />1 <br />Cross Street <br />T <br />Y <br />Owner/Operator r� S <br />Name <br />Phone # <br />Phone # <br />oContractor <br />N <br />T <br />ContraCtor Address <br />CA Lic # Class <br />R <br />A <br />Insurer <br />Work Comp # <br />TICC <br />Technician's Certification Number <br />Ei*ation Date <br />R <br />ICC InsiaWs Certification Number <br />Expiration Date <br />Tank ID # <br />ls Stored <br />Tank Size <br />y <br />Date UST Installed <br />Cuuneennt usly <br />T <br />A <br />u <br />K <br />P <br />UApproved <br />/)Reproved with conditions UDisappmved <br />L <br />(See Attachment With Conditions) �f--2 `3 A> <br />N <br />Plan Reviewers Name <br />Date �i <br />APPUCANT MUST P_EERFFOk?1[. 1LL hAORIC IAOCOF2DA NCE.hAlTT}{.SAN J44MMCCLR+[TY.Oi�91DtA61C�,S .FATE LAWS,: At [3 BLAES AeD_REq� c)FSAN <br />JOACLM CO[Y", ENVIRO MEIJTAL FEALTH :APARTMENT. OWNER OR LC84SM AGEIVS SKMTt1RE CERTIFIES THE FOLLCVA4G: -1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR VWICH THIS PERMIT IS ISSUED. I SHA(L NOT EMPLOY ANY PERSON IN SUCH A MANNER ASTO BECOME SUBJECT TO <br />WORKER'S <br />C.OM PE?7SA LAWS OF CALU;CRMA' CONTRACTOR'S <br />HIRING OR Sr -NATURE CEtTWIES THE POLLOv&Ja 9 CERnFY <br />THAT IN THE OF THE VVOFtK FOR VINCH THIS PERMIT IS M1®, I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAVYS <br />OF `ALIFOfiNIA` <br />g <br />AppLartsSic�a4re <br />Tdfe / / Dale d <br />BILLING WFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff tine expended beyond permit payment coverage per tank_ ff <br />the party designated below is different than the permit applicant, e.g. property owner, the party must adbwwledge this <br />responsibility for the bitting by signature and date below. <br />f p� M ` <br />NAME e f 1 i V 1 ( I i L la TITLE � 'l � _PHONE # <br />EH23D038 (revised 8/8!06) <br />1 <br />