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F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />c <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 Cast 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 />n THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />OTANK RETROFIT �IPING REPAIR/RETROFIT n <br />LIUDC REPAIR/RETROFIT <br />EPA Site # Project Contact &Telephone # <br />Facility Name ^ i?J� /� <br />Address I L 'ST F Phone # w� _ qS 2 — ZZ <br />Cross Street <br />Owner/Operator <br />Contractor Name ��D to <br />Contractor Address (y� <br />Insurer <br />ICC Technician's Certification Number <br />ICC Installer's Certification Number <br />Tank ID # <br />Plan Reviewers Na <br />Phone # <br />Phone # <br />CA,, CA Lic # —7 (l 3 / & D Class <br />L Work Comp # 3(-12 (oZLt <br />5 5 O C/ &;J Expiration Date <br />Expiration Date <br />Tank Size Chemicals Stored <br />Currently/Previously Date UST Installed <br />--JHpproved with conditions ODisapproved <br />Attachment With Conditions) <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: "I CERTIFY <br />THAT LI THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />THAT <br />CALIFORNIA." <br />ll <br />d <br />- f'Z, - 0 <br />bILLINU 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 />SIGNATOR <br />EH230038 (revised 8/3/07) <br />1 <br />PHONE * <br />