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0 a <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 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 �B D START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name d> Phone# <br /> 1Address R 6 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator12 L <br /> EA 13Phone# <br /> C <br /> Contractor Name . �� Phone# <br /> T Contractor Address W* CA Lic# ?j Class <br /> R Insurer Work Comp# <br /> A <br /> Q ICC Technician's Certification Number Expiration Date <br /> T <br /> QICC Installer's Certification Number Expiration Date <br /> R <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approvedproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A 7, <br /> i N Plan Reviewers Name Date_ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMEN AL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WO K 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 L S OF C IFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE THE FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" „dl <br /> Applicants Signature Title Date V <br /> BILLING INFOR ATIO : <br /> Indicate the respo le party to b4(ed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is d'fnt than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility <br /> 77for the billing by sig <br /> ,,,��tuuAreeA and date below. -� I e <br /> NAME_W FSN /'"R�t"t{J.i 11��TITLE 800.5R— <br /> nP/H�ONE# KJ �� "�-J�� <br /> ADDRESS ( F� I1�-rdle-^ r .Q <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />