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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Tkird 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 BELOW <br />UTANK RETROAT LIMPING REPKVRFTR0RT I 111rr t7roc ID <br />APPLICANT MUST PERFORM ALL 1LUM IN 403ORDAr CE WrTH SAN J3AaJ1r1 al 17Y ORXUANCES, STATE LAWS, AND RUES FS AND-RECA"TIONS CF SAN <br />"CON COUNTY, ENVIROWENTAL HEALTH DEPARTMENT, 01MJ OR UCD3 AGEIJPS SIGNATURE CERTIFIES THE FOLLOVANG: 'I CERTIFY THAT tN <br />THE PERFORMANCE OF THE AURK FOR VVHICH THIS PERMIT IS ISSC , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRMOR SUBCONTRACTING, S)SNATURE CERTIFIES THE FOLLOWING: 'I CGZTIFY <br />THAT IN THE PERFORMANCE OF THE; VVORK FOR VVH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORYl MP <br />s COMPENSATION LAWS <br />OF CALIFORM <br />Amts Date J <br />BILLING INFORMATION. - <br />Indicate the responsible party to be billed for additional EHD staff ti^Ie 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 billingbysignature and date below_ �[ l <br />NAME �C1►���ii7 �1Ci4'� TITLEt�I�l_ (.�W[-:itHONE#� �" Yc�-��� <br />2 t <br />SIGMA <br />EH230038 (revised &WO6) <br />F <br />A <br />I EPA Site # <br />ProjectCanta� & Telephone # <br />✓vVv W V <br />V' i <br />C <br />Facility Name <br />Address <br />t <br />Cross Streel <br />T <br />y <br />ner/Operator <br />1 <br />Phone # <br />C <br />O <br />nlractDr Name •�_ <br />;-on <br />Phone # <br />T <br />tractor Address r i.- r' <br />� 1 <br />LLic # <br />Class <br />R <br />A <br />Insurer <br />n <br />Work Comp # <br />�- <br />T <br />T <br />ICC Technician's C rtification Number <br />Expiration Dam <br />R <br />ICC Installer's Certification Number- <br />Ezpira5orl Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currentfy/Previousty <br />Date UST installed <br />T <br />A <br />u <br />K <br />P <br />r Appmved <br />proved with conditions <br />UDisapproved <br />L <br />(, chrir°nt With Conditions) <br />A <br />N Plan Reviewers Name <br />�. <br />Date/ <br />APPLICANT MUST PERFORM ALL 1LUM IN 403ORDAr CE WrTH SAN J3AaJ1r1 al 17Y ORXUANCES, STATE LAWS, AND RUES FS AND-RECA"TIONS CF SAN <br />"CON COUNTY, ENVIROWENTAL HEALTH DEPARTMENT, 01MJ OR UCD3 AGEIJPS SIGNATURE CERTIFIES THE FOLLOVANG: 'I CERTIFY THAT tN <br />THE PERFORMANCE OF THE AURK FOR VVHICH THIS PERMIT IS ISSC , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRMOR SUBCONTRACTING, S)SNATURE CERTIFIES THE FOLLOWING: 'I CGZTIFY <br />THAT IN THE PERFORMANCE OF THE; VVORK FOR VVH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORYl MP <br />s COMPENSATION LAWS <br />OF CALIFORM <br />Amts Date J <br />BILLING INFORMATION. - <br />Indicate the responsible party to be billed for additional EHD staff ti^Ie 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 billingbysignature and date below_ �[ l <br />NAME �C1►���ii7 �1Ci4'� TITLEt�I�l_ (.�W[-:itHONE#� �" Yc�-��� <br />2 t <br />SIGMA <br />EH230038 (revised &WO6) <br />