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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 PTITOEXP S 1,800 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT PIP G REEPAY' ROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> I EPA Site# Project Contact&Telephone# � r <br /> � <br /> Facility Name p Phone# je7_ —� <br /> Address CZ <br /> 14T <br /> Cross Street ��o , (A <br /> Y Owner/Operator 1.19 Phone# Sig)"�'3 O� <br /> Contractor NameS•7® ,J �p Phone#ZQ <br /> Contractor Addressgb t4o . CA Lic# 3C::?/ Clas o G6t <br /> Insurer Z Work Comp# 6 <br /> ICC Technician's Name Expiration Date Ll f g 2 <br /> ICC Installer's Name p Expiration Date 3 Z <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> e 87 pp,ng sumo.91 leak deteaw,UDC 12 etc) Installed <br /> r i <br /> K <br /> I <br /> i <br /> Approved Approved with conditions ❑ Disapproved <br /> L ( (See A achment With Conditions) k <br /> F. <br /> N Plan Reviewers Name ate <br /> A;:;;LICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> J=QUIN COUNTY, ENVIRONMENT L HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> Tnc PERFORMANCE OF THE WOR OR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> ',YORKER'S COMPPIE�NSIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> AT IN THE PERFO OF TH WORK FOR WHICH S PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> :ALIFORNIA" <br /> .ants Signature V Z eeln � <br /> BILLING INFORMATION: <br /> Inc cate 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 billing by signature and date below, n n' <br /> NAME OTgV� (,L9�} 1'��_ TITLE �`` ! �L a*Q PHONE <br /> ADDRESS � <br /> �i SIGNATURE DATE 6 <br /> EH230038(revised 02/20/0 \ <br /> Off_ 1 <br />