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6 tr' ►`�tr th y' 1 1r 1 4 yh44 1,NK �. ,•y4i! ►r t 4 ►. y r r ► r 'i'��ttM <br /> / ¢ r t t h . i` ► ti i 4 r � 4 Yrs r► :; <br /> / <br /> I ' <br /> I i <br /> ._f ► Y4 I - 1 Yr Y r IY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 - <br /> { Telephone: (209)468-3420 Fax: P09)468-3433 <br /> APPLICATION FOR I UNDERGRIJUND STORAGE TANK <br /> RETROFIT-OR P <br /> (PING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 186 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT D PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Tele..hone#__'_ <br /> _ A __. p. <br /> O Facility Name ," .l 1 r CPhone <br /> L Address ��t <br /> I Cross Street <br /> Y Owner/Operator t i,,iCr Phone# <br /> ° Contractor Name c� <br /> ° Phone# <br /> N Contractor Address <br /> T CA Lk;# <br /> R Class <br /> Insurer <br /> A + Work Comp# <br /> T ICC Technician's Name <br /> ° Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> P.o.87 Piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved proved with conditions El Disapproved <br /> A !J� (Se �ttac ment With Conditions) <br /> N Plan Reviewers Name <br /> Date___ <br /> ......_ ... -------- --'---- - <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTALHEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PER IS ISSUED,I SHALL NOT EMPLOY ANY PERSON.IN SU..CH A.MANNER_AS.IQ BECOME SUBJECT TO <br /> WORKER' -LAWS: CALIFbRNIA" CONTRACTOR'S HnNG OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 9 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO,1 SHALL EMPLOY PERSONS SUBJEGT.,TO WORKER'S COMPENSATION.LAWS.: .. <br /> OF-CAL1FORN1A - <br /> Applicants Signature1' <br /> 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 /> responsibility for the billing by signature and,date elow. <br /> him Wirt <br /> NAME LI����.�(�[�(�[ �/Me) _TITLPHONE <br /> ADDRESS—__ <br /> J <br /> SIGNATURE_�1 DATE i <br /> 6i <br /> EH230038(revised 08/1111) <br />