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0 <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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT E PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# h i I`}✓} 4(01-V55? <br /> C Facility Name �'�r t�r�j �� Phone# - <br /> l Address , <br /> L <br /> I Cross Street <br /> T Phone# <br /> Y Owner/Operator C, <br /> C Contractor Name Phone# <br /> N Contractor Address CA Lic# ���(� Class 'C© AZ <br /> T e <br /> R Insurer �(� Work Comp# 1 <br /> A <br /> C ICC Technician's Name Expiration Date <br /> T <br /> ° ICC Installer's Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1121 etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L eP Attachment With Conditions) <br /> 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, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE 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 A OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFOOMP0 MAN OF HE CALIF R IA." H THIS PERMIT!S ISSUED,I SHALL EMPLOY PERSONS SUBJEC�TOWO�RKER'S OMPENSATION LAWS <br /> OF CALIFORNIA."Applicant's Signature a <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 /> responsib' for the billing by signature and date below. - <br /> fy) ` ] lam. � CE ti yy • <br /> NAME �� C ` TITLE40NE# <br /> ADDRESS MlAfa M <br /> SIGNATURE r DATE <br /> EH230038(revised 4811111) <br /> 2 <br />