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ENVIRONME TAL 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 /> X THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> 1LJ[ANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# C `, c A- D� w <br /> A <br /> C Facility Name O Phone# C / a S <br /> I Address <br /> L `3 3 O 4 INP 14 a->'A 7V1 v- a N e <br /> I Cross Street <br /> T <br /> Y Owner/9perwater N —c'eZ_ d LA- eA-S T Phone#(,q/-6:-)7.7-0 <br /> Contractor Name Phone# <br /> i E ©, A161-633Z <br /> T Contractor Address 2 6- 3 5 wt CA Lic# G G 00 7 el Class Q C-/O y- if Z <br /> A Insurer Work Com P t / 7 7 9 00 <br /> ti^ A � 7r© 2 I A N p# 0©� <br /> TICC Technician's Certification Number <br /> T Expiration Date <br /> RICC Installer's Certification Number <br /> R b-a .S R 3 45 ® Expiration Date 0 5-_ f 2 '" p 7 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> C--- /v I< Ai 0 W f./ .30 ©o v 5>7,,-, <br /> IN <br /> N <br /> K <br /> P ❑Approved ,Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A ffI <br /> N Plan Reviewers Name Date CI-13- 0-7 <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: "1 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 ,C G� Title J ee / S ►�/ Date p ' // d <br /> BILLING INFORMATION: <br /> Indicate the r nsible 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 T _ TITLE PHONE# — 3 3 <br /> ADDRESS ?y S� �(s e /� t / et A& -� f/' � S �o� / o AJ <br /> SIGNATURE <br /> EH230038(renis 8!8/06) <br /> 1 <br />