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• a <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, 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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br />F <br />EPA Site # j <br />I Project Contact & Telephone # <br />A <br />D <br />Facility Name Y S" <br />Phone # <br />I <br />Address 6 O , S 1'�l <br />TCross <br />Street <br />Y <br />Owner/Operator luPhone <br /># <br />oContractor <br />Name <br />Phone # <br />N <br />T <br />Contractor Address �Q <br />CA Lic # 4 Class <br />A <br />Insurer r© Z^ -S <br />Work Comp# v 2 O 6 <br />C <br />T <br />ICC Technician's Certification Number _,. <br />Expiration Date 6 O Y -� 3 �-• <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />11Appr0 ved Npproved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date -d-7161 <br />T— <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WIT SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER 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 COMPENSAT14W%1,AWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMA CE NE THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA" c <br />Applicants Signature Title G� i Date 1J I 2;2,/ , <br />BILLING INFORMATION: <br />0-7l <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 />responsibili for the billing by signature and date below. Ate. <br />NAME I�SC� tl '�� TITLE PHONE # <br />ADDRFSS 0 V( 1XrAA om J' � I lI r [A/ <br />t <br />SIGNATURE <br />EH230038 (revised 8/8/06) QO <br />