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ENVIRONA.NTAL HEAL': DEPARTMENT <br />SAN JOAQv�av CUUNTY' <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209).468 3420 . Fax: (209) ,468-3433 <br />APPLICATION FQR:UNDEAROUND. STORAGE TANK RETROFIT OR: PIPING REPAIR PERMIT <br />�-77 <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPRbVAL DATE. INDICATE PERMIT TYPE BELOW: <br />DTANK RETROFIT _ BPIPING REPAIR/RETROFIT E]UDC REPAIR/RETROFIT <br />F.. EPA Site #; : Project Contact Telephone # <br />A- <br />115 <br />C Facility Names Phone # <br />L Address G T <br />�. <br />I Cross Street <br />T:. _ <br />y Owner/Operator ` (!lone <br />c Contractor Name <br />tl .. Phone:# <br />N ContracorAddtess <br />:C' '. CA Llc #:� +� Class t <br />- R R.N. <br />• <br />/._. <br />A Insurer '.. Work Comp # _ <br />T. ICC Technician's Certification, Number Expiration Date <br />R ICC Installer's CerdficaHon'Number' Expiration Date <br />It <br />Tank ID # Tank Size.. Chemicals Sfoced Date UST' Installed <br />Currently/Previously <br />T <br />K ..,�. <br />P ElApproved rovedmith conditions ❑Disapproved <br />e tta ment With Conditions) <br />A: <br />N man' Reviewers Name <br />,..(..,A Date . 2 _ ..I <br />_.. <br />APPLICANT OUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGt7LATiONS.OF SAN <br />JOAQUW,COUNTY, FNVIR(N�IMENT•AL W. ALTI v..DEPARTMENT. OWNER OR LICENSED AGENTS. SIGNATURE QERnms;THE FOLLOWING— ."I CERTIFY THAT IN <br />THE -PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNERAS TO BECOME SUBJECT TO <br />WOli i'S .COWEN8ATION.LAWS OF: CALIFORNIA." CONTRACTOR'S, HIRING OR SUBCONTRACTING•.SIGNATURE .CERTIFIES THE FOLLOWING. "9 -CERTIFY <br />7 Fil9T.M3 E.R I E OF.THE WQRIi..FOR WHICH THIS <br />PERMIT. IS ISSUED; I SKAU EMRLOY FEFtSONS SUBJECT T� WORKER'S COAAPENSATION LAWS <br />• OF CALFORNIA. % <br />Applicants -S _ . _ •: _ W . , x y. Dal® <br />WE ` , GI � FORMAI7ON; <br />[ndi>rate :the responsible party: o be balled #or add�honaLY W. sta# Ime expended beyorrzl Vermit' payriient coverage per' fatiic If ' <br />- — <br />daSl9naie ieivw s-difiereni n-the�pbtrfltt' appl[cant, prope gWner,�e pa . -mus --a this :; <br />re pponsiibiilityy4br the billing by signature and date below. ' I <br />NAArIE 7 �J� I 1 C�h� _ T z r11 O� ,�1 . �C PHONE # � <br />AD©w_ s 25 (1%►ME <br />.SIGNATURE <br />F.H23OM8 (revised 8/8106):. , <br />