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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 RETROFIT OR PIPINGI PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT JK PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name C--;` `� \� ,� n _ Phone# ® s <br /> LAddress <br /> TCross Streett- <br /> Y Owner/Operator ® C-� p4.,�- b '°' hone# ak °Z) ^ ®Gcn <br /> C Contractor Name —� C.,,, , r ry `c$ 5 Phone# ®e�) <br /> O <br /> NContractor Address 112 lb® ®,r - CA Lic# 5SBOq9b Class A, <br /> 16s <br /> R Insurer r Work Comp# <br /> A �r r ca.-- f� �.c a.�-- -,s-�,ter <br /> C T ICC Technician's Name .� -� ®L Expiration Date "� �� <br /> _ <br /> o <br /> R ICC Installer's Name Expiration Date N <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 j ® t 1 <br /> A <br /> N <br /> K <br /> P ❑ Approved [YApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name Date <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 ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO 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." <br /> Applicant's Signature Title 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 /> responsibil'y for the billing by signature and date below. <br /> NAME TITLE s�� PHONE#-f&'12 ^� <br /> ADDRESS <br /> SIGNATURE ` DATE <br /> EH230038(r ise 02/20/09) <br /> 1 <br />