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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUM COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETR <br />OFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />�. <br />Ej. TANK.RETROFIT "❑ PIPING REPAIR/RETROFIT `tbC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F EPA Site # Project Contact & Telephone # <br />A. , <br />C FacilityName <br />a. `� Phone # <br />Address - 1 <br />1 CL <br />T <br />Cross Street <br />Y Owner/Operator <br />Phone .# <br />o . Contractor Name <br />N Phone.# <br />T Contractor Address <br />R . _ C A Lic # Class <br />A Ipsur� (� C1c� ��\ J �o <br />C <br />_ Y�,�"U � � • - Work Comp <br />T ICC Technician's Name <br />o Expiration Date <br />R ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Re• 87 plp�8 sump, 91 bek detector, tmC trz, ee.l Tank Size Chemicals Stored -Currently Date :UST <br />Installed <br />T <br />A <br />N <br />K <br />P ❑ Approved <br />�. Approved with conditions ❑ Disapproved <br />A (See Attachment With Conditions) <br />N: <br />Plan Reviewers Name <br />7 <br />_ Date Tt <br />APPLICANT MUST PERFORM ALL' WORT( 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: "I CERTIFY THAT IN <br />THE o R E RMC0MP NsA-nO YORK FOR-W LIFORNIS PERMIT ALTO ED, 1 SHALt:•NOT-EMPLOY ANY_PERSON'IN SUCH A-MANNER A$ TO BECQMESUBJECT <br />- <br />TOINORKER'SGOAIPENSATION LAWS OF:CAL1) ORNIA " .CONTRACTOR'S HIRING. OR SUBCONTRACTING SIGNATUhE CERTIFIES THE.FOLLO ECO "I CERTIFY . <br />THAT IN-THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITIS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />Applicant's Signatu�('�{Z$L <br />Title Date. <br />BILLING INFORMATION: <br />Judicate the: responsible party to be belled for additional EHD staff fime expended beyond permit payment coverage per tank. f <br />-the..- Party tiesign�ted below Is ,differerrt than the.permft.;applicant;` e.g. -property owner, the party must` acknowledge this <br />responsibility for.the btllitig by signature and date:below. <br />NAMFF.Iitv 1 elnCp►.Irli1�n11 <br />TITLE y Y -J PHONE , <br />ADDRESS�JC� <br />SIGNATURE . , <br />DATE <br />EH230038 (revised 02/20[09) <br />- 1 <br />