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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 <br />A <br />EPA Site # <br />Project Contact & Telephone # <br />C <br />Facility Name <br />Phone # 9 <br />01 <br />I <br />L <br />Address <br />TCross <br />Street <br />Y <br />Owner/Operator <br />CI <br />Phone # <br />c <br />o <br />Contractor Name <br />� {� <br />� <br />Phone # <br />_ t <br />TContractor <br />Address <br />A Lic # <br />Class <br />R <br />A <br />TICC <br />Insurer <br />Work Comp # <br />O( <br />T <br />Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area Tank <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Size Chemicals Stored Current/ y <br />T <br />A <br />N <br />K <br />P ❑ Approved pproved with conditions ❑ Disapproved <br />L (See Attachment With Conditions) <br />A _1�1 � 1 <br />N Plan Reviewers Names � r Date 0p <br />7 <br />Date UST <br />Installed <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 AGENTS 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 <br />TO 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 />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 <br />and date below. t*n , I <br />NAME��1}�1 _ Q���y l TITLEEN qj �( PHONE <br />ADDRESS_ e�p <br />SIGNATURE _ �1•� <br />— _ DATE <br />EH230038 (revised 02/20/09) <br />1 <br />