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0 0 <br /> 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 <br /> 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 IJDC REPAIRIRETROFIT IJ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A ( 760—?yj -/ <br /> C Facility Name i Phone# <br /> I Address �C� <br /> T Cross Street r-7 <br /> Y Owner/Operator �/` Phone# 2c� <br /> NContractor Name wed, ^� Phone# <br /> T Contractor Address 75_C t CA Lic# g Z Class �j N <br /> AInsurer� , ,r' _ <br /> Work Comp#7/ <br /> aICC Technician' N4� <br /> o s Name t — �f Expiration Date ` <br /> R ICC Installer's Name ° Expiration Date <br /> Z_ <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e,87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T F` 4 Cert t'_S e' <br /> A <br /> K <br /> P E Approved pproved with conditions Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name; <br /> _ Date �� ! <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAOUIN 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WO FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." / <br /> Applicank's Signature Title ( { Date <br /> BILLING INFORMATION: <br /> Indicate the responsibl party to be FOR <br /> 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. <br /> NAMES PHONE# <br /> ADDRESS6"�4-j <br /> SIGNATURE. - i � DATE <br /> EN230038(revised 08/1/11) <br /> 2 <br />