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0ti • <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 /> ANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 'A <br /> A <br /> C Facility Name 0 _ � Phone# C7�. IZ) _414 <br /> I Address <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# _ <br /> oContractor Name Phone# <br /> N <br /> T Contractor Address2ffi5A Lac# 66CM6 Class <br /> R <br /> A Insurer AM awz com PANY 6F AmEmAWork Comp# r <br /> Q ( co <br /> C <br /> IGC Technician's Name Expiration Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 Beak detector,JCC 1/2.etc,) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved VApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name AA - f�4A Date r 'tet <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 PERFORMANCEOF 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 SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature_ ��MGj itle_ ,ffifffI 1;L46 Dake 9 <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 <br /> ybby�signature and date below. y} <br /> NAMEIUL�Ji l�_j_� �!—TITLE � I 8 L!V V PHONE <br /> ADDRESS_ l J♦J__.-.1�5 ��Le—� 1�l _�.[�• CJ fAJ t ) <br /> SIGNATURE �J`,�� DATE <br /> EH230038(revised 02120109) <br /> 1 <br />