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ENVIRONMENTAL LTHDEPARTMENT <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 PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> APhone# <br /> C Facility Name <br /> I Address <br /> L <br /> Cross Street <br /> T <br /> Y Owner/Operator as Phone# <br /> oContractor Name Phone# <br /> N Contractor Address (" CA Lic# ® -79,3 Class <br /> T <br /> A Insurer r Work Comp# Q meg p ®® <br /> c ICC Technician's Certification Number Expiration Date ! J <br /> T <br /> Q <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P Approved ❑Approved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date 11 S�c3 <br /> 00r- <br /> APPLICANT MUST PERFORM ALL ORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, IRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANC O 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 COMPE SA ON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERF RMA E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO W RKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." J <br /> Applicants SignatureJ61 * � <br /> BILLING INFORMATION: <br /> Indicate the responsi a 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 apikilicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date bel w. <br /> NAME v t ITLE PHONE#—d4A 9A,21 <br /> 61 yj _j , V <br /> ADDRESS ' <br /> SIGNATURE <br /> EH230038(revised 12/3 /07) <br /> 1 <br />