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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 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 />r - <br />Facility Name ) S' Phone # <br />Address 21% <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />LAA <br />Phone # <br />C <br />Contractor Name <br />Phone # <br />0 <br />N <br />Contractor Address o �S <br />CA Lic # Class <br />T <br />rn <br />' <br />R <br />A <br />Insurer <br />Work Comp # <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name r <br />Expiration Date <br />Tank system work ared <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved �4pprovecl with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />[ <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL W K INA CO ANC WITH SAN JOAQUIN COUNORD�/ANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED G SS IGNATI IRE 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 <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 PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Title 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 />responsibi ' or t g bi�ia by signature and date below. �J/�(j 2h <br />NAME < TITLE PHONE# /tet/"/'����lJ <br />ADDRESSSO Lo" 5510 5 <br />SIGNATURE ��P/ L. e�// r DATE !) 11+10q <br />1 <br />EH230038 (revised 02/20/09) <br />1 <br />Zr-)� <br />C -3b <br />