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i <br />'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 El PIPING REPAIR/RETROFIT DC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />FCEPA <br />Site # <br />Project Contact & Telephone # <br />Facility Name {Y\, <br />Phone # <br />I <br />L <br />Address y� <br />® 0 <br />T <br />Cross Street <br />Y <br />Owner/Operator j" <br />Phone # <br />C <br />Contractor Name <br />Phone # L <br />T <br />Contractor Ad dres <br />CA Lic # Class <br />R <br />A <br />c <br />Insurer <br />i <br />Work Comp #Q 1 <br />T <br />ICC Technician's Name <br />Expiration Date ` 1-1(9011 <br />°ICC <br />R <br />Installers Name <br />' <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />e Attachment With Conditions) <br />A <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 />THAT IN THE PERFORMANCE OF THE WOR FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OFCALIFORW4.! <br />Applicant's Signature Tile <br />ME <br />V DILLIIVV IIVI'UKIVIfi I IUIV: <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 parry must acknowledge this <br />responsibilit for the billing by signature and date alo <br />NAME , LE y d PHONE# L � <br />01 <br />