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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 ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project C ntact & Telephone # <br />C <br />Facility Name ILLPhone <br />• <br />IAddress <br />L <br />5 <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # _ <br />o <br />Contractor Name <br />R <br />R <br />Phone # <br />NContractor <br />T(CA <br />Address <br />Lic # <br />Class <br />A <br />Insurer, u <br />Work Comp h c0ft 25-- lt`. 10, <br />C <br />T <br />ICC Techni ' n's Name <br />Expiration Date <br />oICC <br />R <br />In Iler's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Current) <br />- y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K� <br />P <br />❑ Approved <br />❑ Approved with conditions <br />❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name <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 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS, <br />OF CALIFORNIA." <br />oma <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 />ftyrNAME ��I�E.L� n � ?I �/ riC TITLE }� �X` <br />.�.i�`E.cY � tL+L�L-�,� �—PHONE # GCri <br />ADDRESS IW-AllyAM (1)Vkifnccnt\G. <br />SIGNATURE <br />EH230038 (revised 08/1/11) <br />