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# • <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 PERMITTYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ,® COLD STARTIEVR UPGRADE <br /> ryEPA Site# Project Contact&Telephone# 2G�I-qq3-3 <br /> Facil tyName Phone# — g�— 1—]2 <br /> Address S24 Cross Street <br /> Owner/Operator Phone# — 9�--77 Z2 <br /> C Contractor Name / Phone# —°193-36X <br /> ° CALic# 3(413-7c: Class A Ho C-/V,L �i <br /> N Contractor Address <br /> T Work Comp# i <br /> R Insurer HG <br /> A <br /> T ICC Technician's Name Expiration Date <br /> ° ICC Installers Name W ` Expiraton Date '1, 1 <br /> R Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e.87 piping sump,91 leek detector,UDC 12,etc.) <br /> T <br /> A <br /> N <br /> K <br /> ❑ Approved ❑ Approved with Conditions El Disapproved <br /> P <br /> L (See Attachment With Conditions) <br /> A Date <br /> N Plan Reviewers Name <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUINH COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS H SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> TO WORKER'S COMPENSAT ONLAWS OF CAL FORNIIAP CONTRACTOR'S HIRWG OR SUBCONTRACTING SIGNATURE CERTIFIES THEAFOLOLOWING:E CEBRTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT le ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Tide Da e <br /> Applimnra Signature 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 by signature and date below. n/to V <br /> NAME 2A rX rj 4) l,, T,TLE��r'�" MCU J3�—PHONE#_20 <br /> ADDRESS <br /> DATE <br /> SIGNATURE <br /> EH230038(revised 02/20/09) <br /> 1 <br />