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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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT FlInrl <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />/n1,^, <br />Facility Name Ph ne # <br />t..(.U+ <br />I <br />L <br />Address <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />o <br />Contractor Name — <br />Phone # <br />T <br />Contractor Address 4 <br />CA Lic # Class <br />RInsurer <br />A <br />Work Comp # 40SO 17 <br />cICC <br />T <br />Technician's Certification Number 6'3 -- <br />Expiration Date _ <br />GICC <br />R <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 />Oo0 <br />N <br />21 <br />K <br />P <br />❑Approved /Approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers NameDateIkZ_ IF <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 HEA PARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FO7CALVRI9HI PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LA CONTRACTOR'SHIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br />THAT IN THE PERFORMANCE O WICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Applicants Signature Title GLI/�h,l.!//w"r/!il'/Yf/7 OliDate <br />BILLING INFORMATION: <br />Indicate the responsible pa y 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 />EH230038 (revised <br />w0 <br />