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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 f:"'J✓ <br />Telephone: (209) 468-3420 Fag: (209) 468-3433 <br />APPLI ON FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPI REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE <br />❑ TANK RETROFI PIPING REPAIR/RETROFIT I�UDC REPAIR/RETROFIT ElBELD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name L, o #1 ZZ <br />on <br />Ph e # as G - S 9 9'()-7(-/(j <br />1 <br />Address 15 5 3 <br />p,i �n A aS3 <br />TCross <br />Street L_k ' <br />Y <br />Owner/Operator gCi`o�_()_ <br />Phone # <br />o <br />Contractor Name ra �;LL ,: <br />Phone# 7 7 <br />T <br />Contractor Address o� f <br />� hVIr <br />Lic # Class <br />R <br />Insurer r <br />�`c (1-\..1� <br />t <br />Work Comp # 9 o Z <br />A <br />CExpiration <br />T <br />ICC Technician's Name ( l n L -� <br />� �r,u 1> <br />Date I _ <br />° <br />ICC Installer's Name - <br />����{�S <br />Expiration Date J <br />((.j <br />Tank system work area <br />Tank Size r" Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />T <br />A <br />N <br />K <br />ry <br />P <br />❑ Approved <br />❑ Approved with conditions ❑ Disapproved <br />L <br />ee Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />v <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDAN WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AN ULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPAR ENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TH LLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THI <br />TO WORKER'S COMPENSATION LAWS OF CALIFORN <br />ERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A M NER AS TO BECOME SUBJECT <br />." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFI THE FOLLOWING: "1 CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR <br />CH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WO ` R'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />K <br />Title __ Date _ <br />Indicate the responsible party to be <br />the party designated below is di <br />responsibility for the billing by sign <br />ADD <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />BILLING INFORMATION: N <br />ad for additional EHD staff time expended beyond permit payment coverage <br />nt than the permit applicant, e.g. property owner, the party must acknc <br />and date below. <br />C c" <br />TITLE 'J PHONE # -)5 6`n <br />1 <br />tank. If <br />hie this <br />X" <br />