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0 <br /> ENVIRONMENTAL HEALTH DE RTMENT <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 <br /> 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 ❑ UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � <br /> Facility Name S L/ Phone# <br /> IAddressPd . e <br /> I Cross Street <br /> T <br /> Y Owner/Operator L4 11 41 Phone# <br /> oContractor Name 10E, Phone# <br /> N <br /> T Contractor Address CA Lic# S Class C (� <br /> AInsurer Work Comp# <br /> T ICC Technician's Name Expiration Date TOIT <br /> R ICC Installer's Name �,(>j A-sn Expiration Date <br /> Tank system work area Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Tank Size Chemicals Stored Currently Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved -�pproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A J <br /> N Plan Reviewers Name Date <br /> Y <br /> /01 <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 COMPENSA ON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMA EO THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature / ✓!"' Title Date /V <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge <br /> this responsibility four the billing by signature and date below. G� ,1 <br /> NAME ( / �� TITLE / GZ� N�PHONE# gO <br /> ADDRESSD D V ✓ /V J (, <br /> SIGNATURE DATE <br /> EH230038(revised 07/22/10) <br /> 2 <br />