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09/19/2008 FRI 11:26 FAX 20 83433 SJC EHD 0001 <br /> ********************* <br /> *** FAX TX REPORT *** <br /> ********************* <br /> TRANSMISSION OK <br /> JOB NO. 1841 <br /> DESTINATION ADDRESS 919163731173 <br /> PSWD/SUBADDRESS <br /> DESTINATION ID <br /> ST. TIME 09/19 11:25 <br /> USAGE T 00' 52 <br /> PGS. 1 <br /> RESULT OK <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 ❑PIPING REPAIR/RETROFIT MUDC REPAIR/RETROFIT ❑COLD START/EVR UPG E <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name Q ` Phone <br /> � Address Vla\ S. <br /> I Cross Street \ <br /> T <br /> Y Owner/Operator \.� Phone# <br /> C <br /> Contractor Name WICIA11 Phone# c (, <br /> N Contractor Address <br /> T \p CALic# � Class <br /> R Insurer <br /> A Work Comp# <br /> C ICC Technician's Certification Number <br /> T _ 'i` Expiration Date <br /> o ICC Installer's Certification Number <br /> R _ t,,,'V Expiration Date \®_ ® _pe <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> ACA <br /> N Q <br /> K SI <br /> P ❑Approved pproved with conditions ❑Disapproved <br /> L (Seettachment WithConditions) <br /> A �j <br /> N 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 AGENTS 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." gg <br /> Applicants Signature Title Date <br /> BILLING INFORMATION: <br />