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ENVIRONM TAL 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 PING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site# i Project Contact&Telephone# e nau .3`j 7 <br /> A <br /> C Facility Name e_ Phone# %-SU-3716 <br /> � AddressQ C:LtiVn <br /> T Cross Street <br /> LJQV <br /> Y Owner/Operatorleca Phone# <br /> oContractor Name Phone# <br /> N Contractor Address —FCA CA Lic# �20�� Class �{ �� <br /> TIrtue <br /> R <br /> A Insurer Work Comp# OW S6 se <br /> T ICC Technician's Certification Number Expiration Date <br /> 9—I <br /> RICC Installer's Certification Number (t . u r Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T 34 1'799 the. e( 0,000 <br /> A <br /> N ! > 2000 <br /> K 0 sod af <br /> P ❑Approved Approved with conditions ❑Disapproved <br /> L See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date__q <br /> U U <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 AGENT'S 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 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 /> Applicants Signature `►—' Title PCO C I Date <br /> BILLING IN ORMATIO : <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 /> NAME !�eoy- , TITLEPf� -n(Ain'epr PHONE# q16- 28K /7 <br /> ADDRESS ��� �j�let- ISM ) l) -! c-9SI'1602- <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />