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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue, Third Floor,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 <br /> 'I BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT XUDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name ttJUC+v�I Phone# 1016ca <br /> I Address <br /> L ^,`�., <br /> I Cross Street �.1 ' q <br /> T <br /> Y Owner/Operator Phone# <br /> oContractor Name (t.Qj Phone# <br /> N <br /> T Contractor Address CA Lic# I Class <br /> A Insurer lnp1 � TK Work Comp# j <br /> T ICC Technician's Certification Number L `; Expiration Date o2 <br /> R ICC Installer's Certification Number Q�5 UW.41 Expiration Date ��, <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T 7 <br /> A qi 1tAf <br /> N <br /> K <br /> P NAPproved ❑Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Ian ReCyi wars Name �' D to ��U6 <br /> d �Y"I i'� r1 B b <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 PERFORMANCE OF THE WORK 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 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 /> Applimrns Signature Titl Dare EJ OXJ(J <br /> BILLING INFORMA N: 13 <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 TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 818106) <br /> 1 <br />