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ENVIRONMENTAL HEALTH DEPARTMENT SAN JOAQUIN -COUNTY 600 East Main Street, Stockton, California 95202 Telephone: (209) 468-3420 Fax: (209) 468-3433 APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: ❑.TANK RETROFIT ❑ PIPING REPAIR/RETROFIDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE BILLING INFORMATION:. Judicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit. applicant, e.g. property owner, the party must_ acknowledge this responsibility for the billing by signature and date below. Kim 11 NAMEE� ewfa&(S I mi TITLE r1G[JI.N VrJ PHONE ADDRES$1� [�S/ 1(U Y141'll ! x i 1 • Il� .�-1�1�-`F� l.� 9520b 67 �r DATE <C� SIGNATURE EH230038 (revised 02120/09) EPA Site # Project Contact & Telephone # F A Facility Name Phone # (5 I l L Address Cross Street T Y Owner/Operator Phone # Contractor Name Phone # - c 0 N Contractor Address A Lic # Class T R Work Comp # Q Insurer A c T ICC Technician's Name Expiration Date R ICC Installer's Name Expiration Date Tanks stem Work area y Tank Size Chemicals Stored Currently Date UST talled, Ins (i.e.ing .e. 87 pipsump, 91 leak detector, UDC 12etc.) - T A N K ❑ Apprc ved Approved with conditions Disapproved P L A See chm 't With Conditions) N : Plan Reviewers Name Date APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. THE -PERFORMANCE OF THE WORK' :FOR. WHICH- THIS. PERMIT IS ISSUED, I SHALL NOT EMPLOY.- PERSON IN SUCH A MANNER AS TO 6ECOME SUBJECT -COMPENSATION HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY . TO -WORKER'S. LAWS OF CALIFORNIA.- CONTRACTOR'S THAT IN THE PERF0RMAbIQE OF THE WORK F R WHICH THIS -PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OFCAUFORNIA.' /�_ I rxe I�P&ff f IA��-AT) ,` V 6 _ Date BILLING INFORMATION:. Judicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit. applicant, e.g. property owner, the party must_ acknowledge this responsibility for the billing by signature and date below. Kim 11 NAMEE� ewfa&(S I mi TITLE r1G[JI.N VrJ PHONE ADDRES$1� [�S/ 1(U Y141'll ! x i 1 • Il� .�-1�1�-`F� l.� 9520b 67 �r DATE <C� SIGNATURE EH230038 (revised 02120/09)