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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUN 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 <br />f BELOW- <br />UTANK RETROFIT UPIPING REPAIWRETRORT ' t UDC REPAtRARETROFIT <br />F <br />EPA SitE # Project Contact & Telephone # C <br />A <br />C <br />cility Name a_ F <br />Phone # $ _ <br />dress5 i <br />rAd <br />L <br />T <br />ss Street <br />Y <br />Owner/Operator nrj <br />Phone # <br />Co <br />ConlractrorName / �_ <br />Phone # 4- /— <br />N <br />T <br />Contractor Address lis # Class <br />A <br />Insurer 0 <br />work Comp # P600,50079 <br />C <br />T <br />ICC Technician's Certification Number <br />Expiration Data <br />O <br />R <br />ICC Installer's Certification Number <br />Expiration Data <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Date UST Installed <br />Currently/Previousty <br />T <br />A <br />w <br />K <br />P <br />LJApproroved with conditions UDisappraved <br />L <br />( Attachment With Conditions) <br />A <br />N <br />J� <br />Plan Reviewers Name N ` Date <br />APPUCANT MUST FERFOELI ALL VVCI K LN: ACCORDANCE TARTH SAN JOACUINCOLWTY ORDINANCES, STATE LAWS AND RULES FS AaD.RECIAATIONS OF SAN <br />"CUN COUNTY, EW ROWBJTAL HEALTH DEPARTMENT. 01N4ER OR LKZ,1SM AGENTS SIGNATURE CERTIFIES THE FOLLOVAIG: -1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT tS ISSUED, I SHAW_ NOT EMPLOY ANY PERSON W SUCH A MANNER AS TO BECOME SI MECT TO <br />WORKER'S C0A;j3ISATION LAWS OF CALIF-CRNIA" CONTRACTOR'S HIRING OR SUBCONTRACTINIG, SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT W THE PERF MANCE OF THE WORT( FOR WHICH -I THIS PERMIT IS ISSI�, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Pn��C ffiIdle G <br />A� Sr �� Gt Date <br />" BIWNG`INFORMATION'-/ " <br />Indicate the responsible party to be billed for additional E1D staff tone 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 />responsibii for the " ri by signat�ur/el and date below_ <br />NAME�.1 U 1 Y TITLE t� 1Gl G PHONE # <br />ISI AA <br />EH23DO38 (revised 8/8106) <br />1 <br />