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0 <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 /> 0 TANK RETROFIT 0 PIPING REPAIRfRETROFIT ® UDC REPAIRIRETROFiT 0 COLD STARTIEVR UPGRADE <br /> F EPA Site# Prood Contact&Telephone# <br /> A <br /> C Facility N Phone# ( r' IL <br /> L <br /> Address 12 <br /> TCross Street <br /> Y owner/QperatoP Phone# <br /> C Contractor Name P # R / <br /> O <br /> T Contractor Address ` CA Lic# 'AN2 6K4U Class <br /> RInsurer mllkmrk Comp#ze <br /> A <br /> CICG T nician's Name �,�{ Expiration Q <br /> T <br /> Q <br /> R ICC Installer's Name Expiration Date tt4wt <br /> Tank system work area Tank We Chemicals Stored Currently C UST <br /> c1 a 87 .81 le .I //Z.em) Installed <br /> T <br /> A <br /> N <br /> K AT <br /> P 0 Approved 3"4proved with conditions ® Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name. AA ®J 0�1 Date <br /> APPLICANT MUST PERFORM All WORK IN ACCORDANCE WITH SAN JOAOWN COUNTY ORDINANCE&STATE LAM.AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OMER OR LICENSED AGENTS SIGNATURE CERTWIES THE FOLL ' 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKERS COMPENSATION LAWS OF CALIFORNIA," C HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOVW40 I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR ICH THIS PERMIT IS ISSUED.l SMALL EMPLOY PERS014S SUBJECT TO WORKEWS COMPENSATION LAWS <br /> OF CALIFORMW <br /> nPa a <br /> rim <br /> Dale " <br /> LIV OILLINIG INFORMATION: <br /> Indicate the responsible party to be bftd for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is dWerent than the permit applicant, e.g. property owner, the party must acknowiedge this <br /> responsibility for the billing by signature and date below. <br /> NAM T1TL .A .r .PHO NE a -.U&QZergot) <br /> ADORE"E <br /> - <br /> $IGNA PURE 1 _DATea'Z3 ` <br /> EHt2300138( s /20109} <br /> i <br />