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� . <br /> 0 <br /> ENVIRONMENTAL HEALTH <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 ROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> OTANK RETROFIT PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility NameChA C7 <br /> Phone# <br /> I Address <br /> L <br /> TCross Street <br /> Y Owner/Operator Phone# <br /> C Contractor Name Phone# <br /> 0 <br /> N <br /> T Contractor Address CA Lic# Soo jjGClass — (j <br /> AInsurer va ap, aWork Comp <br /> cICC Technician's Certification Number Expiration Date <br /> T <br /> R ICC Installer's Certification Numberp <br /> Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K 1 <br /> 7 <br /> L VV <br /> P ElApproved ><Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date001 <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 PERFORMANCHE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMP SATI N LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT INTHE PER RMAN E F THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPS SATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title ® Date 06 <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 forte illing by signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS �66d 141 "' <br /> SIGNATURE <br /> EH230038(revised 8/8/06 q <br /> 1 <br />