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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 #GAL d 14 <br />6 <br />Project Contact & Telephone <br />C <br />Facility Name A --o /,j e�7 <br />&��b <br />Phone #y,y6 1 .- <br />1Address <br />7 w — <br />T _ 7 4�Lr S. <br />TCross <br />Street <br />`V <br />Y <br />Owner/Operator <br />Phone #. 6� <br />C <br />o <br />C <br />Contractor Name UQ f <br />- <br />Phone #�S <br />T <br />Contractor Addresslei - <br />(� Q?L <br />CA Lic # 773 `^ Class 1 . <br />RInsurer <br />A <br />Work Comp # <br />TICC <br />T <br />Technicians Name <br />' l( <br />Expiration Date <br />QICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i. e. 87 piping sump, 91 leak detector, UDC 12, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />TJ�-d <br />l <br />A <br />N <br />K <br />P <br />❑ Approved <br />❑ Approved with conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name <br />Date <br />APPLICANT <br />MUST PERFORM ALL WORK IN ACCORDANCE <br />WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. <br />OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OFT 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 COMPENSATIPN LAWS OF CALIFORNIA." CONTRACT 'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCV THE WORK FOR WHICH <br />OF CALIFORNIA." <br />THIS P IT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />Applicant's Signature <br />Title v Date <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 and date below. j�� / \ <br />NAME �1„ 1 �-7 TITLE L/ W!i/`42APHONE mag <br />SIGNATU <br />EH230038 (revised 02/20/09) <br />1 <br />