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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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT D PIPING REPAIRIRETROFIT D UDC REPAIR/RETROFIT U COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name O Phone# �- <br /> I <br /> L Address <br /> TCross Street <br /> Y Owner/Operator 'Q Phone# <br /> G Contractor Name <br /> o Phone# �)• <br /> N <br /> r Contractor Address ' — CA Lie# Class <br /> R Insurer rr ! <br /> A l� Work Comp# <br /> C ICC Technician's ame <br /> T Expiration Date <br /> oICC Installers Name <br /> R Expiration Dale <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sung,91 leak dete or,UDC 12,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with Conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers NameDate ♦Z <br /> c <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 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 COMPENSATI LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM NCOF THE WORK F,0FZ WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." � 1 ,p n• I'y�1�1/-� —7 <br /> Applicant's Signature 1 Title <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 /> responsibilit for a billin by,signature and <br /> date below. ��/� <br /> NAME L I12 n r C76 TITLE (1P _PHONE# ,�/0 <br /> �t rr' mI Ile,✓ <br /> ADDRESS 10� ]�1` <br /> ko <br /> SIGNATURE r DATE �/,ry 11� � <br /> EH230038(revised 08/1/11) r 'T <br /> 2 <br />