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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE, 3RD FLOOR STOCKTON, CA 95202 APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK RETROFIT _PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT +---------------------------------------------------------------------------------------------------------------------------------+ EPA SITE # ; PROJECT CONTACT & TELEPHONE # ------------------------------------------------------------------------------------------------------------------------------ F ; FACILITY NAME ; PHONE # A+--------------------------------------------------------------------------------------------- C ADDRESS L I CROSS STREET , I+----------------- ---------------------------------------------------------------------------- T OWNER/OPERATOR PHONE # Y --------------------------------------------------------------------------------------------------------------------------------- C I CONTRACTOR NAME I PHONE # O+----------------------------------------------------------------------------------------------------------------------I N 1 CONTRACTOR ADDRESS I CA LIC # � CLASS , T+------------------------------------------------------ -----------------------------------------------------------------I R INSURER ; WORK.COMP.# , A'----------------------------------------------------------------------------- +-------------------- ---------I C OTHER INFORMATION , T+--- -------------------------------------------------------------------------------------------------------------- 0 -------+------------------------------ O , , PHONE # PHONE # ---------------------------------------------------------------------------------------------- ��IIII TANKI ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T 39- A 39- N 39- K 39- 39- 39- P L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED A (SEE ATTACHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE DATE +------------------------------- --------------------------------------------------------------------------------------+ Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. Name Address Phone # Signature EH230038 (revised 1/31/02) 1