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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 RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRlRETROFIT ❑ UDC REPAIRlRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name �L �c Phone# <br /> Address <br /> TCross Street <br /> Y Owner/Operator Phone# ; -I <br /> oContractor Name Phone# <br /> N Contractor Address <br /> T CA t_ic# Class <br /> R Insurer ^� <br /> A Work Comp# QC�L4• 1 <br /> C <br /> T IGC Technician's Name Expiration Date <br /> DICC Installer's Name 1 <br /> R ��,' > Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.B7 piping sump,91 leak.detector,UDC 1/2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved L7 Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N <br /> Plan Reviewers Name_ <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 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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING.OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i SHALL EMPLOY PERSONS SU9JECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> /., ty - <br /> Applicant's Signature_ itIe_ �rO_U q&_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 biill�lifnyg bby�sig/n�eattu�r(e nand date below.. y� <br /> NAMEEI i�U ��n Q3C 4 TITLE_ t ftlI V6 PHONE Lu — <br /> ADDRESS_ _ <br /> SIGNATURE _ —_ _DATE <br /> EH230038(revised 02120109) <br /> 1 <br />