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ENVIROWNTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> RETROFITAPPLICATION FOR UNDERGROUND STORAGE TANK 1 1NG REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone <br /> C Facility Name l Phone# - - 7044"7 <br /> L Address � eawrnimT �3 <br /> TCross Street <br /> Y Owner/Operator s M Ud Phone# <br /> CContractor Name I Phone# ( - �®2 <br /> 0 <br /> N Contractor Address '] G A Lic ' I Class - <br /> T <br /> R <br /> A Insurer Work Comp# <br /> C <br /> T ICC Technician's Certification Number c/ — Expiration Date ///0 / <br /> R ICC Installer's Certification Number 5 Expiration Date ls- o <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved PApproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N <br /> Plan Reviewers Name Date 6 U�® <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "1 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." rZ <br /> Applicants Signa ®.A Title Date <br /> re <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment overage 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 TITLE PHONE <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/8/06) <br />