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ENVIRONMENTAL/ L 1-1EALTH_ DEPART ENT <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 PIP <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROt/ALDATE INDICATE PERMIT �N� REPAIR PERMIT <br /> O.TANK.RETROFIT ❑ ELow: <br /> PIPING REPAIR/RETROFIT'❑ UDC REPAIR/RETROFIT LD START/EVR UPGRADE <br /> F. EPA Site# <br /> A Project Contact&Telephone# <br /> c Facility.Name <br /> t <br /> Address Phone# <br /> Cross Street . <br /> Y '.OwnerlOperator, <br /> o ContractorName Phone# ., <br /> o. <br /> N Contractor Address Phone# e <br /> T — <br /> R Insurr A Lic?Wor <br /> Class <br /> T_• " 5 ��� <br /> C_ _• '!tik Cam ,� <br /> T. ICC Technician's Name p <br /> R ICC Installer's Name . Expiration Date <br /> Tank system work area Expiration Date <br /> (Le.87 P'*9 snmp,91 leak defector,uoc 1/z e1c.) - Tank Size <br /> Chemicals Stored Currently Date:UST <br /> T Installed <br /> A <br /> N <br /> K <br /> P ❑ Approved <br /> LApproved with conditions <br /> A (S At <br /> N tachment With Conditions) Disapproved <br /> Plan Reviewers Name <br /> APPLICANT MUST PERFORM ALL'WO N ACCORDANCE WITH <br /> JO9OPER COUNTY,ENVIRONMENTAL EALTH DEPARTMENT,OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 9 CERTIFY T <br /> SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> 7HE PERFORMANCE_OF THE_yDRK, R-WHICH- - <br /> T0�TAN TER'SERiy7PENSq nON LBWS OF:CALI Rl�laP C� A ARES HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:, T 1 <br /> HALL-NOT EMPCDY gryy pERgON IN_SUCH A 1CAANNER q$ fp`gECOME SUBJECT <br /> T.FC LI THE PERFORMANCE OF THE WORK FOR.WHICH THIS=PERMIT IS ISSUED 1 SHALL EMPLOY PERSONS SUBJECT TO.WORKER'S COMPENSATION LA W$ <br /> OF CALIFORNIA" _ WING: '1 CERTIFY <br /> Applicanrs Signati �( <br /> Tier�u' 1 <br /> BILLING INFORMATION: Date. <br /> lndlcate the responsible Harty to be billed for additional EHD staff time expended beyond permit_payment coves <br /> the_'party designated below is different than the.permit._applicant e, <br /> responsibility for the bi)6ng by signature and date'below. ge per tank. :If <br /> g. property owner; the party.must:acknowledge this <br /> NAMFE� �p Cn' yy��TT�I <br /> _Tr <br /> is l I lr!Y ly i PHONE 1 <br /> ADDRESS . <br /> SIGNATURE <br /> EH230038(revised 0 <br /> 2/20/09)- ATE <br /> I <br /> i <br />