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• • I <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 -fbJDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />D <br />Facility Name {Y`'1 <br />Phone # (� . <br />I <br />L <br />Address <br />TCross <br />Street <br />Y <br />Owner/Operator '— y" <br />Phone # (� <br />C <br />Contractor Name <br />Phone # LJ <br />0 <br />N <br />T <br />Contractor Addres <br />CA Lic # Class <br />R <br />InsurerEIIA <br />Work Comp # J �Q <br />A <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />I <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />leak detector, UDC 112, <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 etc.) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(S =Qhment With Conditions) <br />Asq(-(o <br />N <br />Plan Reviewers Name Date <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 />MIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />THAT IN THE PERFORMANCE OF THE WLz::Zitle <br />OF CALIFOR " r 4 \ <br />�,�-'^" Lo <br />Applicant's Signature <br />Applicant's— <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 I elo <br />NAM, E �"'`�PHONE � <br />E <br />AD <br />SIC <br />EH------ --- -- -- - <br />1 <br />