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0 1 <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 ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# (Z % z oGI� 30 8 77 <br /> APhD e# <br /> O Facility Name r") g' Z{Qo L, <br /> I Address 29 3 2 n, �< <br /> Cross Street , <br /> TPhone# z6 9 �,j D - 8'7'7 F- <br /> Y Owner/Operator q <br /> C Contractor Name Phone# ( Zoe}) <br /> 0 <br /> NCA Address CA Lic# r �' , lass <br /> T <br /> A Insurer / Work Comp# <br /> G ICC Technician's Certification Number Expiration Date <br /> T <br /> 0ICC Installer's Certification Number Expiration Date <br /> R <br /> Tank ID# Tan i e Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approv dpoved with conditions ❑Disapproved <br /> L (Seetttachrment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WOR IN ACCOR ANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DE RTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH T IS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFOR IA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FO WHICH THIS PERMIT IS ISSUED,I SHALL :MPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature A Title a— Date <br /> BILLING FORMATION: <br /> Indicate the res n ible party to be illed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party desig ed below is 'ferent than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by sig ature and date below. <br /> NAME C� e �� TITLE ( ! (r PHONE# l o / / - E1�� <br /> ADDRESS ZO 2 "S®q L, [Ji A Sj <br /> SIGNATURE <br /> EH230038(r iF12/31/07) <br /> 1 <br />