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ENVIRONMENTAL HEALTH <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 REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT COLD START/EVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone #7 _ <br />A <br />C <br />Facility NamePhone# <br />j-(0 Ll <br />Address g t <br />T <br />Cross Streete j 4 ` <br />Y <br />Owner/Operator <br />Phone # _ b <br />CContractor <br />Name Yvi O <br />Phone # <br />N <br />T <br />Contractor Address g� - <br />CA Lic # Class <br />R <br />A <br />Insurer <br />Work Comp # .- — <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name , <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Cheo I Dtalled e UST <br />0 a 87 piping sump, 91 leak detector, UDC 112, etc.) <br />T <br />A <br />201 <br />SEP 2 <br />N <br />K <br />SRN EALTH <br />DEPARTMENT <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />A <br />(SegAftachment With Conditions) { <br />- <br />N <br />Plan Reviewers Name Date f <br />APPLICANT MUST PERFORM ALL WORK IN ACCORD 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: "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 <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 />Olym izo 9 � / <br />Applicant's Signature Titte Date CX <br />BILLING INFORMATION: <br />Indicate the responsible party to 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 by signature and date below. ,/% /� <br />NA . TITLE! / J2 PHONE # �J !/ 6- <br />EH230038 (revised 02/20/09) <br />1 <br />TE <br />