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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, 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 <br />EPA Site # <br />Project Contact & Telephone # " t C <br />A <br />C <br />Facility Name - <br />Phone it <br />L <br />Address <br />TCross <br />Streetj��Y <br />Y <br />Owner/Operator Phone # Ct <br />o <br />Contractor Name ` <br />Phone.# <br />T <br />Contractor Address ) <br />CA Lic # llLlSl�l J l �q Classt <br />Aft <br />A <br />Insurer <br />Work Comp # L506 1 _0 <br />T <br />T _ <br />ICCTechnician's Certification Number <br />Expiration Date <br />o <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P❑Approved <br />Approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date a aq <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ' <br />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: "1 CERTIFY <br />THAT IN THE PERFORMANCE OF. THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY FERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />I <br />Applicants Signatul-_6 _ 01-A& Date <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 />NAMES TaTL6 W_PHONE # � <br />ADDRIsSS L 14�i �t. 1 1 ��v nn C.' ev,-5, )S . <br />SIGNATURE <br />EH230038 (revised 8/8/06) <br />