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ENVIRONM NTAL HEALTH D&ARTMENT <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 LIMPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT SOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# �" VL AM '-7 ,D C <br /> A <br /> C Facility Name Phone# .- <br /> I <br /> L Address 1990 A�OCx � Q)h n CA <br /> '�t ► � al, <br /> TCross Street <br /> Y Owner/Operator w►(w-.� Phone# C_ q 3j- <br /> C Contractor Name ''1�Z ��- yAl Phone# <br /> 0 <br /> N Contractor Address' <br /> T �,J), 93 � SWWT�-kb q51,J11 CALic# SClass 1E)-'Dqo <br /> R Insurer Work Com # <br /> A ��1 1� �`�• p ` alDOW 18 00`II <br /> cICC Technician's Certification Number <br /> T �'��� (,,)i Expiration Date o <br /> R ICC Installer's Certification Number -2 c�.27 - Expiration Date j J - 3- 69 <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approv d pproved with conditions ❑Disapproved <br /> L (S a Attachment With Conditions) <br /> A �/ <br /> �/I/q,— <br /> N Plan Reviewers Name66� Date GIF- <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 kMW" LSVVA-6AjA Date <br /> BILLING INFORM ION: <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 TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />