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SEP -6-2006 10:258 FROM:D&SDRAOLNE SVC 2098268699 4683433 P.2 6 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNT' <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 />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPEBELOW' <br />V <br />LITANK RETROFIT JPIPING REPAIR/RETROFIT LUDC REPAIR/RETROFIT <br />F <br />EPA Site # Project Contact & Telephone # 58'7- 151 <br />� <br />Facility NameL)IIA46-1APhone # g 3Z- S&A 2, <br />Address 3L Jq 3 `.'r'�Q (A 1j56,(p <br />TCross <br />Street <br />Y <br />Owner/Operator , 11 10- <br />Phone # of a.`5j <br />C <br />Contractor Name t>4 S Znc <br />XC <br />Phone # (2,pq '3,21,-1:5 ?1D <br />T <br />Contractor Address S q'�S�O <br />CA Lie # 53 ) Class A I wy)ZI Com% <br />A <br />Insurer l t5ry J Work Comp # 0Ce0tAaS- <br />T <br />ICC Technician's Certification Number xm L Expiration Date I I, p <br />R <br />ICC Installer's Certification Number �j Z Expiration Date <br />Tank ID # Tank Size <br />Chemicals Storad Date UST Installed <br />Currently/Previously <br />T <br />A <br />N <br />K <br />P <br />UApproved pproved with conditions I.JDisappmved <br />L <br />(SeAAchment With Conditions) <br />A <br />N <br />t ..1r <br />kN. WA "l `1-06 <br />Plan Reviewers Name Date <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 COMP NS TION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING' "i CERTIFY <br />THAT IN THE PER NCE E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." ( 1 <br />Ap Iicarris lignatu Title 1041 nil Date <br />BILLING INFORMATION: v <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. t� ^� <br />NAME��J 1\ ("(1� , w' -qUe _ dSla. � TITLE PHONE* i� U�D-ff <br />5-1Q <br />ADD <br />EH230038 (revised 8/8108) <br />1 <br />