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0 <br />0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, Califomia 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THI PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />D TANK RETROFIT (PING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />C <br />Facility Name <br />Phone # . -Y <br />I <br />L <br />Address <br />I <br />cross street <br />Y <br />Owner/Operator , '"" <br />, Phone #' <br />c <br />Contractor Name <br />Phone# <br />0 <br />N <br />Contractor Address ' <br />CA Lic # Class <br />T <br />RR <br />Insurer <br />Work Comp # qpli <br />T <br />ICC Technic iaan's Name <br />$,� Expiration Date <br />° <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size Chemicals Stored Currently <br />Date UST <br />(Le.8T0*9=1491 isskddecW.UDC1@, ft) <br />Installed <br />A <br />N <br />K <br />P <br />❑ Approved <br />IfApproved with conditions ❑ DIsapproved <br />L <br />( e A chment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORD WITH SAN JOAAUIN 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 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: N CERTIFY <br />THAT IN <br />THE PERFORM AN ' OF THE I{ORK OR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Applicant's Signature <br />Title Cap Emil nef, t Date <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed Poor 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 by signature and date below. <br />ZUEAWAVEWWZTI-dl=:.��+a'a�Ji l i�(i1t.Fil�+ I!L f�1 ;iiL•1iL <br />EH230038 (revised 10/3(Y12) <br />2 <br />