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• S <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 PING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name ' Phone# <br /> 1Address <br /> L / <br /> Cross Street <br /> Owner/Operator Phone# 240 <br /> o Contractor Name Phone# - <br /> N Contractor Address CA Lic# <br /> T lass <br /> R <br /> A Insurer Work Comp# <br /> cExpiration Date Q ICC Technician's Certification Number .,3�dL j c f-� p� <br /> T - ter <br /> ° ICC Installer's Certification Number Expiration Date <br /> R <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T K 1 0 L <br /> Nrct., T <br /> K <br /> P ❑Appro L proved with conditions ❑Disapproved <br /> L (S Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date—, <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN NTY 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANCE OF TH WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> kpplicants Signature Title Q Date <br /> BILLING INFOR ATION: <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 /> sponsitilityfor the billing by signature and date below. p <br /> NAME �!� TITLE I�IC[/IP— PHONE#(Laf) <br /> ADDRESS <br /> SIGNATU <br /> EH23 38( vised 12/31/07) <br /> 1 <br />