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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 RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name 1 L.1 2 <br />Phone* <br />1S <br />3 3 <br />[Z4C,4q c5 3 <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />C <br />Contractor Name `() <br />Phone # 2-o�f _ 3 V S--/ 2!L b <br />TContractor <br />Address <br />CALic# —ty 0 Class <br />RInsurerA <br />F C% c a- Co <br />Work Com # 3 f-1 -Z,(, 2,Lt -7 <br />DICC <br />Technician's Certification Number tLrLsrit <br />Expiration Date l - t-t._Q <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Date UST Installed <br />Currently/Previously <br />T <br />A <br />N <br />K <br />P <br />I ..]Approved <br />144proved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name ��l.R- <br />( y <br />/Vbtw-I� Date 6YI I iv8 <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. <br />OWNER OR LICENSED .AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT <br />IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S <br />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT <br />IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA" <br />Applicants Signature <br />��QQ <br />Title '/4d Date 2i (J <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 by signature and date below. <br />NAME <br />EH230038 (revised 8/3/07) <br />