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07/30/2908 WED 15: 23 PAX 2094683433 5JC EHr 0003/030 <br /> - ENVIRONIP.-ATAL HEALTH [m)"EARTMENT <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 EXPiR,_=3 180 DAYS FROM THE APPROVAL CATS INDICAl'EFERWT TYPES3 <br /> ._.___JTANK RETROFIT :]PIPING REPAIR/RETROFIT [&: DC­R_Ej�'��ORR TROFfT L COLD ST--r,-,!EVR JPGRADE <br /> F EPA Site# Project Contact&7elephone ft <br /> A <br /> Fac city Name -[�Var_lz s. # <br /> C <br /> L Address c. <br /> q!;� r_J it <br /> T Cross Street <br /> Y Owner/Cperator J, <br /> Phone# -C <br /> rc Contractor Name ,` # <br /> C,a 1.9-69 kf_2 6-3 <br /> Contractor <br /> Z CA L ic Class <br /> Insure, Wo&Comp A <br /> i <br /> ICC:Technician's CerttificaJn_Number Expi,abon Date 4L:t-/ <br /> _R fCC Installer's Certification Number 1 Expiration Date <br /> Tank ID Size Chemicals Stored Date UST installed <br /> Curren IlyiProvio u s.y <br /> T <br /> A <br /> N 1 ----1— <br /> L t* L4 0, <br /> ..................... <br /> 4— <br /> P '...IApproved 1-1 <br /> Approved with cond cork ,Di3approved <br /> L (See Attachment With Conditions) <br /> A <br /> IN Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORS*, IN ACCORDANCE WITH SAN JOAQUN COUNTY ORDINANCES,STATE_,WVS,AND RILLES AN0 REGULATIONS OF SAN <br /> PDACUJN COUNTY,ENVIRONLAIENTAL HEALTH 0EPAPTAIENT, OWNER:%R UCENSE[l AGENT'S S!GNATiRE Cz�VFIF IES ThE FCLLDWI'4G- N CERTIFY THAT IN <br /> 'HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT S.SSUED,I SHALL NOT EMPLOVANY FIER]irt, A hIANNERAS TO BECOME SUBJECT TO <br /> NORKERS CONIPENSATION LAWS OF CALIFORNIA.' CovrRACTOR'S HIRING OR S1,JBC,:)NTR-^,CT!r,1G SICNATUR' "R7 t=ZZ T-IE FOLLOINING 1 CERTIFYTHAT 114 THE PERFORMANCE OF T�-E WORK FOR WHICH'HIS PERkJIT! <br /> OF CALIFORNIA." I I IS E&JED.I S. ALL MPL:�, PEPSZ�NS;SU3"�TG WORKER'S CGI 0PENSA71ONAWS <br /> Date <br /> BILLIN01N FORMA7 10N_ <br /> Indicate the responsible early !o be billed for additicral EHD staff time expended beyond peririi I ayrneni coverage per tank. If <br /> the party clesigratod below is cifferent than the permit applicant, -3.g. rroperty ooiner, ilre, party tTILISt acknowledge this <br /> -esponsibility for the billing by signature and date below. <br /> TITLE 61, <br /> R <br /> )(SIGNATURE —--------- <br /> E-1230038(revised 12/31107) <br />