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• <br />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 *jDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # o (9/0876-38 0 <br />� <br />Facility Name imm ut- &@,qF- 76 <br />Phone # <br />/^ <br />Address Z ®� W - Ha wt rte e- ii LLj.N✓!Of' <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />C <br />O <br />Contractor Name DAZES-SEIZ <br />Phone # <br />N <br />T <br />Contractor Address 2L5i 7 E L--� f <br />CA Lic # *3'2. jClasS4 e <br />R <br />A <br />Insurer %ic',' <br />Work Comp # h <br />W '7 •11!! C� % 11 <br />T <br />ICC Technician's Name A'�9t, ,ej l <br />Expiration Date 7- 1 <br />o <br />R <br />ICC Installer's Name y, �� l� <br />f L <br />•- <br />Expiration Date (o- 9—M <br />Tank <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved pproved with conditions Ll Disapproved <br />LSee <br />Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Na Date 3 <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 AGENT'S 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." i <br />Applicant's SignatureTitleDate <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 />l <br />NAME</C41 / -'a/r a TITLE / <br />�f `fitCf [ PHONE'� C L ^3 JCS <br />ADDRI <br />SIGNA <br />EH230038 (revised 02/20/09) <br />1 <br />TE ? -I`) ua 1 <br />�5c <br />3 <br />