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0 0 <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 13 - -3p S--Cr 6 <br /> A <br /> � Facility Name Phone# <br /> � <br /> Address SZ -7 <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> C Contractor Name Q„�lgS ' v 1v��S - Phone# <br /> 0 <br /> T Contractor Address X310 $, A-/Mg ,q-yL 6&r ALic# `jp2ojs ClassCcC G( l 04to A � <br /> A Insurer v S.O T, 7:3:�h 5V my`L- Work Comp#(,)C3Zg14317165-0 <br /> T ICC Technician's Certification Number 259y043- U Expiration Date /h Y j -2 VV 9 <br /> R ICC Installer's Certification Number R 2 Z�J�/ Expiration Date 'I�2G o 9' <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T ( ©1 eSe(r <br /> A 171 e Sem <br /> N <br /> K eL <br /> U n le.a�.c cQ <br /> Prew� - tU n 1-eCl � <br /> P ❑Approved Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAW ,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." (� <br /> Applicants Signature Title S U rV i$o r Date J <br /> lo K <br /> BILLING IN ORMATION: <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 /> responsibilityforthe billing by signature and date below. 2 <br /> NAME U-% TITLE TITLE 5UJ)ef PHONE# 21'3 <br /> ADDRESS 1 -101 S , A-t rvt c, ay 2 Cc-,- . q(32- 49 <br /> SIGNATURE F v <br /> EH230038(revised 12/31/07) <br /> 1 <br />