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SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL HEALTH DEPARTMENT
<br />304 E WEBER AVE, 3RD FLOOR
<br />STOCKTON, CA 95202
<br />APPLICATION FOR UNDERGROUND TANK RETROFIT. OR PIPING REPAIR PERMIT
<br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW
<br />TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT
<br />1 EPA SITE # 1 PROJECT CONTACT & TELEPHONE #
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<br />1" '1IIIIITANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE UST INSTALLED ,
<br />39-
<br />I T 1 39-
<br />I A 1 39-
<br />I N 1 39-
<br />I K 1 39-
<br />39-
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<br />1 L 1APPROVED APPROVED WITH CONDITION(S4)DISAPPROVED
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<br />A 1 (SEE AT'TAC}A1ENT WITH CONDITIONS)
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<br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF
<br />SAN JOAQUIN COUNTY, ENVIRO1,A1ENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY
<br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO ,
<br />BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.” CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE ,
<br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO ,
<br />COMPENSATION LAWS OF CALIFORNIA."
<br />I APPLICANT'S SIGNATURE: TITLE �j // ;�AG1047r DATE
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<br />BILLING INFORMATION:
<br />THAT IN THE
<br />WORKER'S
<br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment
<br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner,
<br />the party must acknowledge this responsibility for the billing by signature and date below.
<br />Name / ' Phs96//.�1,B Address % ,5/ Poi �3r1/oi Phone #
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