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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 />OTANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name EWRI LIT-( <br />hone # 3,33 <br />Address 6 , D CD <br />DWI <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator pitI Phone # 4 <br />o <br />Contractor Name - i 1 ` s <br />Phone.# <br />T <br />Contractor Address ' ) a&_Mn <br />CA Lic # llClil� ✓LJ l �q Classt <br />AInsurer <br />Work Comp # <br />T <br />ICC Technicians Certification Number <br />' <br />Expiration xpiration Date <br />O <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />Aee <br />N <br />DApproved Approved with conditions ❑Disapproved <br />Attach eV�I%Conditions) <br />Plan Reviewers Name 0 <br />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: "1 CERTIFY <br />THAT IN THE PERFORMANCE OF.THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY FERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />APPlicants Signature 6 r 11 17V\1_� i'itle b.Q j its kNa t W _Date ._f 1 �h_�_,M 1 <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. <br />NAME �h� TITLE i(Q� PHONE # <br />ADDRrSs 7 � 4_ 25 . <br />SIGNATURE/ 11 1 Vltl�( <br />EH230038 (revised 8/8/06) <br />