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ENVIRONMENTAL HEALTHDEPARTMENT <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 REPAIRIRETROFIT AfCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> r Phone# a— <br /> C Facility Name� 1i1 <br /> LAddress <br /> T Cross Street <br /> Phone# <br /> Y Owner/Operator ��.� Phone# <br /> c Contractor Name — — <br /> o CA Lic# 1 Class <br /> N Contractor Address <br /> T Work Comp# <br /> R Insurer <br /> A , \ Expiration Date <br /> TICC Technician's Name Ci V <br /> o �. Expiration Date <br /> R ICC Installer's Name Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) <br /> T Q e� <br /> A <br /> N <br /> K <br /> PElAppro d <br /> Approved with conditions ElDisapproved <br /> L ( e achment With onditions) <br /> A Date <br /> N Plan Reviewers Name <br /> INANCES,STATE LAWS,AND RULES AND <br /> JOAQU NNCOUNSTYPENVIRONMENTAL ORHEALTH DEPARTMENT.OWNER ORLICENSEDAGENTS SIGNATURE CERTIFIES THE FOLLOWINGREGULATIONS CERTIFY THAT AN <br /> JOAO <br /> NNER AS TO BECOME SUBJECT <br /> THE ORKER'S PERFORMANCE EOF THE NSATIONLAWS OF CAL CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> TO <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAW <br /> OF CALIFORNIA." �-- <br /> (�� ,cli�• r1�1 Date <br /> Applicant's Signature <br /> Title\JJ\\ D� <br /> BILLING INFORMATION: <br /> Indicate the responsible pally ibilled for dlot D staff eexpended coveragend permit payment er k <br /> the party designated belows dfferntthanhepermiapplicant, e.g. popertyoner, the pay mut acnowledgethis <br /> responsibility for the billing by signature and date below. <br /> E TITLE �. `t "'W-PHONE# <br /> NAM <br /> ADDRESS <br /> DATE <br /> SIGNATUR � <br /> EH230038(revised 02/20/09) <br /> 1 <br />