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• • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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 ®UDC REPAIR/RETROFIT OCOLD START/EVR UPG E <br /> F EPA Site# Project Contact&Telephone# \_ 3-'71t6 <br /> � Facility Name Q �S Phone# <br /> L Address �'��� 5• C �-� ra <br /> TCross Street <br /> Y Owner/Operator Phone# S t C) _1051- :�Sbp <br /> C Contractor Name Phone# Ql(c <br /> N Contractor Address "� \�j — CA Lic# �`n Class �. <br /> T ,, \\ <br /> A Insurer `3t'p+ Work Comp# -lr)o 011 -U <br /> T ICC Technician's Certification NumberExpiration Date . - CL-1 �9 <br /> R ICC Installers Certification Number 5 _ UT Expiration Date \�_ \�_pa <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T \O k 1 <br /> A loft 2 <br /> N QL <br /> K 3 S K `t 1 <br /> P OApproved pproved with conditions ❑Disapproved <br /> L (Seettachment With Conditions) <br /> A <br /> N Plan Reviewers Name Aytis ! ec 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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: N 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 \ Date — U� <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`sign`at`ure and date below. <br /> NAME �.`�c�,r.a o. W e% TITLE PHONE# ��b - 3-t3 <br /> ADDRESS .C) 71 nx oda- ,3 . � CSA RS vt k <br /> SIGNATURE <br /> EH230038(revised 12/31/0 <br /> 1 <br />