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ENVIRONMENTAL 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 />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />UTANK RETROFIT 6PIPING REPAIR/RETROFIT KUDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />D <br />Facility NamenJJ ' /®,E- 10 <br />Phone # 20_ 3 -.538V <br />L <br />Address <br />TCross <br />Street ( Z <br />Y <br />Owner/Operator <br />Phone # 4;Aj0/ ,- <br />O <br />Contractor Name <br />Phone # a / 57 3 <br />T <br />Contractor Address -o' <br />CA Uc # -74,? 3Y Class ,01 - <br />A <br />Insurer �� <br />Work Comp # rim 74 q —.A' <br />T <br />ICC Technician's Certification Number <br />Expiration Date ' <br />R <br />ICC Installer's Certification Number 4 -q-20 jJ / <br />Expiration Date /Z - 2-g Zc)c:>cb <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />" <br />/ <br />N <br />A <br />- <br />N <br />•' :J <br />K <br />-7 <br />_ <br />kAttac=nt <br />P <br />UAppraved with conditions UDisapproved <br />L <br />( With Conditions) <br />A <br />N <br />Plan Reviewers NameN � ISG Data �j • ZSS - 0 <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 AGENTS SIGNATURE CERTIFIES 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 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" 7 <br />Applicants Signature Date <br />BILLING INFORMATION: <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. ,C n <br />NAME ✓C h' 13u4 cls / -TITLE / '0 LL f PHONE # )-35- 26 -<y <br />38 <br />ADDRESS / % ? / !- hLI- 9 86 l�/j /) (moi <br />SIGNA <br />EH230038 (revised 8/8/06) <br />1 <br />