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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 PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />El TANK RETROFIT -❑ PIPING REPAIRIRETROFIT UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F EPA Site # <br />AProject Contact & Telephone # <br />. <br />C Facility Name Phone # <br />I Address <br />T. <br />Cross Street <br />y Owner/Operator Phone # <br />C <br />D Contractor" Name Eli <br />Phone.# <br />NContractor Address �/\ <br />T �� W'1-l1hJ 1 ClassA V <br />AInsurer , ` ®ork Comp # <br />C o <br />T ICC Technician's Name Expiration Date <br />R ICC Installer's Name <br />Expiration Date <br />Tank system WorkM,area Tank Size Chemicals Stored Currently Date:UST <br />(i.e. 87 PIPh9 smnp, 91 leak detector, uoc , etc-) Installed <br />T <br />A <br />N <br />K <br />P ❑ Approved pproved with conditions ❑ Disapproved <br />1.L <br />A Attachment With Conditions) <br />N Plan Reviewers Na R <br />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: "1 CERTIFY THAT IN <br />THE -PERFORMANCE QF THE, WORK"FOR; WHICH -THIS PERMIT IS ISSUED, I SHALL -EMPLOY ANY -PERSON IN SUCH A -M NNER AS TO.`BECOME SUBJECT <br />TOW&AKER'S.00MPENSATION LAWS OF.CALIPORNIA.` CONTRACTOR'S HIRING.OR SUBGONIRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />OFCALI THATINTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF:CAUFORNIA." <br />Applicant's Signature <br />Date <br />BILLING INFORMATION: <br />Indicate theresponsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the, pa designated below is different than the. permit..applicant, e,g. -property owner, the party must_ acknowledge this <br />responsibility for the billing <br />billing by signature and date below. <br />NAMF� I U l!L J�O Cf� pj\I/' rye. 1 <br />» gam/ TITLE B .71�� PHONE <br />. _. <br />ADDRESS�C� I(1��S�VYV.1'[ CI Pi _l�952V . <br />SIGNATURE <br />DATE <br />EH230038 (revised 02/20/09) <br />l <br />