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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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIR/RETROFIT O COLD START/EVR UPGRADE <br /> F EPA Site# MProject Conte T le h n # <br /> � Facility Name �r? -HOP / , Phone# r��3 <br /> Address e SS J • 7/O y��^ <br /> 1 Cross Street <br /> Y Owner/Operator V�V r' S L L Phone# ylJ y / y , <br /> CContractor Name Phone# <br /> N Contractor Address CA Lic# Class <br /> T <br /> R Insurer Work Comp# <br /> A <br /> TICC Technician's Name Expiration Date <br /> R ICC Installers Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Dat <br /> (i.e.8]piping sump,91 leak detector UDC 1/P,etc) nstalled <br /> ►�. ,S OOt7 a-Od0 <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L Attachment With Conditions) <br /> A <br /> N Plan Reviewers Na Date <br /> APPLICAM MUST PERFORM ALL WORK IN ACC NCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF TH RK FOR 4PERMIS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSA N � CTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMAN H WOERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATIONLAWS <br /> OF CALIFORNIA."Applicant's SignatureTitleL GINFORMATION: <br /> Indicate the respo le party to bnal EHD staff time expended beyond permit payment coverage per <br /> tank. If the party d ignated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this respons bility to the billing by signature and date below. /����r� <br /> NAME-1y/ _4 TITLE—0-m/ <br /> PHONE# <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230038(revis /22/10 <br /> 2 <br />