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• 1 L <br />ENVIRONMENTAL HEALTH DEPA TMENT <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 RETROFITPIPIIVG REPAIR/RETROFIT ❑UDC REPAIR/ RETROFIT [I COLD START/EVR UPGRADE <br />Project Contact & Telephone # `ja5k 2 <br />�82f�,-1S�k <br />F EPA Site # Wl ���- Phone # 2E—Vs-� <br />A Facility Name �C. �'1 �, <br />1 Address <br />L <br />I Cross Street VC3 �st <br />T Phone # z <br />Y Owner/Operator ` _ Phone #Z - <br />c Contractor Name Z �— Class A- ��Z <br />Q �� �' CA Lic # �p <br />T Contractor Address Work Comp # - j , ,p01---)017 9 12 <br />A Insurer "�` _ Imo-' Expiration Date Z— <br />c ICC Technician's Name �jtJC ril <br />T Expiration Date <br />R ICC Installer's Name S �' Date UST <br />Tank system work area Tank Size Chemicals Stored Currently Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) \ <br />T <br />K <br />P ❑Approved 91 <br />Approved with conditions ❑ Disapproved <br />L (See Attachment With Conditions) � `� !� if <br />A �'����� Date <br />N Plan Reviewers Name ' `'1 <br />TAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S EMPLOYIANY PERSONGNATURE IN SIUCH A MANNER R AS TO BECOME SUBJECT <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REG"I CERTIFY ULATIONS H T I <br />JOAQUIN COUNTY, ENVIRONMEWING: 1 CERTIFY <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NO <br />LLO <br />TO WORKER'S COMPENSATION AWS OF CALIFORNIA." <br />FOR NI CIH THIS CONTRPERMIACTOR'S <br />ISSUED, SHALL OMP OY PIERSOINS SUBJECT TO WORKER'SOCOMPENSATION LAWS <br />THE <br />THAT IN IFORIA." PERFORMANCE 4\.2--k I 1 <br />OF CALIFORNIA." � �A� Date <br />Title v <br />Applicant's Signature— BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time exp ended b yondn permit the party nt mu t acower tank. If <br />the party designated below is different than the permit app <br />licant, . responsibility for the billing by signature and date below. PHONE # <br />TITLE <br />NAME <br />ADDRESS <br />SIGNATURE-- <br />EH230038 (revised 02/20/09) <br />1 <br />