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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 />❑TANK RETROFIT PING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # Project Contact & Telephone # <br />A <br />O <br />Facility Name wi <br />Phone # .---- <br />I <br />L <br />Address -7 UinA.--CIA <br />TCross <br />Street <br />Y <br />Owner/Operatorr�Y` (� 7' <br />Phone # �---, <br />C <br />Contractor Named I <br />Phone # <br />O <br />�4t�W`Z, <br />NContractor <br />T <br />Address v <br />CA Lic # 5 1 d Class D J <br />R <br />Insurer �,, ^ <br />Work Comp # �d Z� �s s <br />T <br />ICC Technician's Certification Number 9�6z '� <br />Expiration Date (; 6 — 7 <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 />❑App ved Approved with conditions ❑Disapproved <br />L <br />(Se A achment With Conditions) <br />A <br />N <br />Plan Reviewers Name t'1 rL' 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 />THEPERFORMANCESWORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPEN ATIO LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />O T <br />THAT IN THE PERF MANCHE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />)01 <br />Applicants Signature Title Date / r <br />1 BILLING INFORMATION: ` <br />Indicate the responsible party t billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is 1 erent than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility` for the billing by signature and date below. /1M /Gi <br />NAME �O CC_ ,�G Q`l o- TITLE �iJ`T PHONE # (9 <br />nnnocce U YI ,i in .A is V' !•/ ]"C�,0,_ � . ! - A- <br />SIGNA <br />EH230038 (revised <br />1 <br />6?1,fj---rd <br />