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N <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 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name �„DJ 45 '�'c v yL STO Phone# <br /> I Address lS. ����� r -12e at,L <br /> I Cross Street SNL On G <br /> TPhone# <br /> Y Owner/Operator ���' <br /> C Contractor Name ry ¢ 6GlS fp vG/r Oti Phone# <br /> N Contractor Address r4-01? CA Lic# -/ Z Class <br /> T p 22 3 'Zc� <br /> R Insurer Work Com # O <br /> A <br /> C ICC Technician's Certification Number2 Expiration Date <br /> T <br /> Q ICC Installer's Certification Number 5Z Z� / U t Expiration Date 45? — ZOOj <br /> R <br /> Chemicals Stored Date UST Installed <br /> Tank ID# Tank Size Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved pproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 140A Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH AAN 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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERF�THEWHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants SignatureTitle Date <br /> BILLING ORMATION: <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. V <br /> NAME 2fo �CG TITLE G/ PHONE#��r <br /> ADDRESS <br /> SIGNATLIR;����� <br /> EH230038(revised 12/31/07) <br /> 1 <br />