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n <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 />DTANK RETROFIT I IPIPINr. RFPAIR/RFTPn1:1T tnfl MCDA mcT.- <br />IF <br />A <br />EPA Site # <br />Project Contact & Telephone # 1`1jt'il �� � ` -qS( -(Q 31 <br />C <br />Facility Name 7 <br />Phone # 20 c C <br />L <br />Address lC,ell 0 <br />I <br />T' <br />Cross Street <br />_ <br />Y— <br />Owner/Operator ` NJ Pic Ar <br />Ua y <br />Phone# E Ot— 'r <br />514 <br />.0 <br />O <br />Contractor Name a <br />, <br />Phone:# <br />N <br />T <br />Contractor Address <br />, b <br />CA Lic # :�� � Class � rA <br />klf� <br />Insured <br />Work Com # p_o <br />T ICC Technician's Certification Number <br />R <br />ICC Installer's Certification Number <br />Tank ID # Tank Size <br />T <br />A f` . <br />N <br />K <br />Expiration Date <br />Expiration Date <br />Chemicals Stoned <br />Currently/Previously <br />Date UST Installed <br />P ElApproved Opproved with conditions 013isapproved <br />L (See Attachment With Conditions) <br />A <br />N Plan Reviewers Name <br />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 MANNERAS TO 13ECOME SUBJECT TO <br />WORKER'S COMPENSATION, LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'f CERTIFY <br />THAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJE T TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA? <br />Applicants Signature 4 Date <br />131LL, I G INFORMATION: <br />tndicate..the responsible party to be billed for additional EHD. staff -time expended -beyond -permit payment: coverager per tank. If <br />the parity designated, below is different than the pemiii applicant,' e.g.. property owner,' the party must acknowledge this <br />responsibility for the billing by signature and date below. p <br />NAME T� LL�fh\ (} TrrLE Ill O �1CXi 9�l �(� I PHONE # <br />,ADDw_sS 2 535 _ W Ili 1 ORM M\lfU i7r15 <br />SIGNATURE 1 <br />EH230038 (revised 818/06) <br />