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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAUIN 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 EPA Site# ®� Project Contact&Telephone# ®�p• zQ ®® 3 f <br /> A <br /> C Facility Name me <br /> Phone# Z® <br /> IAddress <br /> L <br /> TCross Street <br /> Y Owner/Operator ° Phone# -.� Z®/ <br /> C Contractor Name Phone# <br /> 0 <br /> N Contractor Address CA Lic# ? or �IT Class, y <br /> T <br /> A Insurer Work Comp# <br /> T ICr nil-^'� t�Y,e Expiration Da /67/.. ®® <br /> R ICC Installer's Namemjmfo Z (-)/ Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T 17 / * <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date /O <br /> APPLICANT MUST PERFORM ALLKIN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMEN L 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 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 2geDate <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 /> NAME POWL AA45< TITLE PHONE# <br /> ADDRESS 7 IAA4&nW "1W �_ <br /> SIGNATURE /� ® DATE <br /> r- <br /> EH230038(revised 02/20/09) <br /> 1 <br />