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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 <br /> RETROFIT OR PIPINGI PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# l) Project Contact&Telephone# rz c P✓ cfc - <br /> A <br /> G Facility Name Phone# <br /> I Address cl <br /> I Cross Street <br /> TPhone# / <br /> Y Owner/Operator v�® <br /> C Contractor Name Phone# /� de/ �6 � <br /> Q �r <br /> TContractor Address ®' S�` CA Lic# 4/;, Class49,-, <br /> A Insurer ��./ �Ir�,t„c �ed�r�r^ ° 3* Work Comp# 14V'7 <br /> T ICC Technician's Name ®L Ita 94'-`1,1,4Expiration Date <br /> R ICC Installer's Name oald AIAr Expiration Date <br /> Tank system work area Tank Size Chemicals 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 /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> LA (S Xachment Wit Conditions) ..-� <br /> N Plan Reviewers Name J1 Date <br /> APPLICANT MUST PERFORM ALL WOR IN ACCO DACE WIT AN JOAQUIN COUNTY O ANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPAR MENT.O NER 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." 7 <br /> Applicant's SignatureJygaZTitle 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 billingg by signature and date below. <br /> NAME o ®�+e� 4 r� vtelOg- TITLE J7(et PHONE# l V� b <br /> ADDRESS 0 /✓+ Ae S141le -*5- 4✓ ®^ <br /> SIGNATURE DATElly <br /> EH230038(revised 0 1) <br /> 2 <br />