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X <br />X - <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 <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name U S— <br />Phone olO�Z alt:, (e & 3 <br />1Address <br />L <br />13 0 ss, <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />oContractor <br />Name ,L �p y� �� <br />Phone # <br />TContractor <br />Address <br />Class <br />AInsurer <br />Work Comp # <br />T <br />ICC Technician's Certification Number "— <br />Expiration DateCC <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />r, <br />lXO0D <br />N <br />S' �- <br />K <br />P <br />❑Approved KApproved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name �� ja ZOO <br />1, Date rL <br />APPLICANT MUST PERFORM ALL WORK IN ACCORD CE WITH SAN JOAQUIN TY 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 />_ 99 ( <br />Applicants Signature 1.�� Title Date �� 1 / <br />/ tiILLINCi INt-UKMAI IUN: <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. M <br />NAME iy/. TITLE "`ate x"2-0 PHONE # D 4/ �O�p 3 <br />ADDRESS / 30 W ✓I UYI "t/ `1 X11 r `� C " J gS-Z <br />SIGNATURE /' G4,VU« <br />EH230038 (revised 12/31/07) <br />11 <br />