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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East :Main Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fac: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL GATE, INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT PIPING REPAIRiRETROFIT UDC R€PAIRIRETROFIT <br /> rF EPA Site# Project Contact&Telephone# <br /> Phone# <br /> Facility Name `Address U y l �(� �o <br /> Cross Street <br /> Te# cL - 4 <br /> Y Owner/open:I I. - �� vQ <br /> D Contractor Name Phone# �A- 7 <br /> T Contractor Address des CA Li0# Class <br /> R Insurer /] Work Comp# '7(3- 27- <br /> A <br /> T ICC Technician's Certification Number Expiration Date <br /> T <br /> Expiration Date <br /> ICC Installer's Certification Number <br /> Chemicals Stored Date UST Installed <br /> Tank ID# Tank Size Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> Approved Approved with conditions Disapproved <br /> P <br /> L (See Attachment With Conditions) <br /> A 00,loe <br /> /1 <br /> Plan Reviewers Name Date (J <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S 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 CALIF NIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANC OF THE WORK OR WHICH III THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> X/OF CALIFORNIA." 2 <br /> Applicants Signature <br /> Titl �' 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 signat re and date elow. <br /> NAME TITLE PHONE <br /> ADDRESS r <br /> SIGNATURE <br /> EH230038(revised 8/3!07) <br /> 1 <br />