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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton,California95202 <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 /> El TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name � r � Phone# <br /> t Address 1 �J <br /> L <br /> Cross Street <br /> T: U► <br /> Y Owner/Operator Phone# — <br /> c Contractor Name 7 <br /> O I {� Phone# _ <br /> N Contractor Address <br /> T CA Lic# Class - <br /> R Insurer <br /> A Work Comp# <br /> C QQ.1 1 <br /> T �ICC Technician's Name `, <br /> '� S Expiration Date CJ <br /> QICC Installer's Name <br /> R Expiration Date <br /> Tank system WorkTank Size Chemicals Stored Current) Date-UST <br /> (i.e.87 Piping sump,91 yak detector,,UDC oc M.etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> A (See achment With Conditions) <br /> N Plan Reviewers Name A&; - '' r� - � <br /> Date_ <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-MNNER AS TO BECOME SUBJECT <br /> TO-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 PERMR ISIS <br /> OF.CALIFORNIA." SUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> ` <br /> Applicant's Signature_- tle hEffi dJLy1AA,LE <br /> Date <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 /> responsibility for the billing by signature and date below. <br /> NAMEC,II"QJ I UI f11QGvL1..� _TITLE � CJ➢r�rl tl PHONEA —CCLJI C1� � <br /> ADDRESS l[J11 <br /> SIGNATURE_ <br /> • DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />