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• 0 <br />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 />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone #2 - �� <br />TArn Phan 269 <br />O <br />Facility Name <br />Phone #10--1i ` <br />1 <br />L <br />Address <br />q <br />ICross Street <br />Y' Owner/Operator ` n <br />Phone # Q 2 1 1 <br />oContractor NameEL <br />'U <br />Phone # <br />N Contractor Address <br />T <br />A Lic # Class <br />94 <br />RInsurer <br />A <br />Work Comp # L� 7 00 <br />cICC Technician's Name <br />T <br />Expiration Date. <br />RICC Installer's Name <br />R <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112; etc.) <br />Tank Size <br />Chemicals Stored Current) <br />y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P ❑ Appro d <br />Approved with conditions El Disapproved <br />!Attachment <br />A <br />( With Conditions) <br />N Plan Reviewers Name <br />Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOA COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature <br />C <br />Title �nJ�[Jt�t { C Lt ME 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 <br />�bjy�signature and dilate below. �l `-I&C�� 7-y� �y, r �2A461-6561 <br />NAME( L �J IJJI t!IQUVl' Q TITLE [ C N1 Tt tlVE)PHONE <br />ADDRESSor <br />��.LC��� 4r f=►1 �L[L! ���J V GV y--- <br />SIGNATUREDATE__ <br />EH230038 (revised 02/20/09) <br />1 <br />?I <br />Al <br />J <br />