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# 0 <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 ❑ PIPING REPAIR/RETROFIT K UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 71-3 <br /> A <br /> O Facility Name ® Phone# 7 t / 2,.,/ .,�' <br /> Address q,3 ,141 <br /> T Cross Street <br /> Y Owner/Operator ���aa�� �� ,�� ��ls Phone# <br /> o Contractor Name L, ✓� Phone# FO <br /> T Contractor Address --� 1� CA Lic# e 0_S Class CCS Z. <br /> A Insurer / '°,I Work Comp# ',y' s <br /> —41 <br /> T ICC Technician's Name Expiration Date r' <br /> RICC Installer's Name d,�, /' � r Expiration Date �,• ''� f <br /> Tank system work area Tank Size Chemi "Is Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> Z_ I t <br /> P ❑ Approved /(SeAftachment <br /> pproved with conditions El Disapproved <br /> L With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDAN WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN Ver <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPAR ENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN (t <br /> THE PERFORMANCE OF THE WORK FOR WHICH THI PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT C J <br /> TO WORKER'S COMPENSATION LAWS OF CALIFOR A." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR HICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS a <br /> OF CALIFORNIA." > <br /> Applicants Signature Title C„r ao i Date /d <br /> BILLING INFORMATION: <br /> Indicate the responsible party to a billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below ' different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing b signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />