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Apr 07 08 10:58a Sandra Barnhart 2098458586 p.4 <br /> 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 REPAIRIRETROFIT DC REPAIR;RETROFIT ❑COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name T-raaq TnALKt Phone �0<1 <br /> I <br /> L Address 91f V, -rra C LLI Lx <br /> I Cross Street L CLL-Ck f4t . <br /> T _ <br /> NJOwnerfOperator j SJ -Ut Phone# a.0cf —�� :3--�00 <br /> CContractor Name , of 1 tkz- --T:n Phone 6111) FV 5 -9S ZS <br /> contractor Address a j? J; :j—,rCA Lic# ?l'37 0 (9 class :�- <br /> Insurer 13C Eyj vWolk Comp# /11 <br /> T ICC Technician's Certification Number Expiration Date <br /> o <br /> R ]CC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Ap ved <br /> roved with conditions ❑Disapproved <br /> L (Se A roved <br /> With Conditions) <br /> A AA <br /> N Plan Reviewers Name V Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUI COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LI ENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOW+NG: "1 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT 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 /> -k-Ap�icar�s5ignatura j ( iI.Y 1w�.7 Title �6 t �C.iC l Date L 2/4 <br /> BILLING INFORMATION: <br /> Indicate the responsible patty 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 /> responsibbil for the billing by signature.and date below. <br /> NAME I`r JCll9if CJtN 1—C� TITLE PHONE# `l r2C7 C� - <br /> ADDRESS ) 1 L I O ` zyzt C.,4 `J <br /> SIGNATUR <br /> EH23DO38(revised 12131/07) <br /> 1 <br />