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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 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 /> � Facility Name )% qV Phone# CPM- - 03 <br /> L Address 1�1 '�p `�ILQp}- 4o <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator 11%S6Phone# <br /> oContractor Name Z ► Phone# <br /> T Contractor Address �y( ' CA Lic# (�� Class ��� b <br /> A Insurer all 'V��w � Work Comp# "a1 Bobo g Wij <br /> QICC Technician's Certification Number Expiration Date <br /> T <br /> O <br /> R ICC Installer's Certification Number Expiration Date //- - <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved VAa <br /> proved with conditions ❑Disapproved <br /> L (See hme th Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> r <br /> APPLICANT MUST PERFORM ALLK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMEN L 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 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." <br /> ns�_ <br /> Applicants Signature ,u�' Titl ti Date I 30 0" <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 /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE Lri� �T <br /> EH230033(revised�0X�1D <br /> L 1 <br />