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F <br />A <br />C <br />I <br />L <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />• <br />ENVIRONMENTAL HEALTH <br />DEPART LVED <br />SAN JOAQUIN COUNTY Nt'r X12011 <br />600 East Main Street, Stockton, California 95202 <br />Telephone; (209) 4683420 Fax: (209) 4683433 EN\IFI0NMElq <br />pEFIMIISERVICESLjH <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 160 DAYS FROM THE APPROVAL DATE. INDICATE PERMITTYPE BELOW: <br />❑ TANK RE=TROFIT ❑ PIPING REPAIRlRETROFIT ❑ UDC REPAIR/RETROFIT R COLD START/EVR UPGRADE <br />EPA Site # <br />Facility Name <br />Address /' <br />Cross Street <br />Owner/Operator <br />Contractor Name <br />Contractor Address <br />Insurer IJA&,f( <br />ICC Technician's Name <br />ICC installer's Name <br />Tank system work area <br />IIT piping rump, 91 IpRI( dotootor, UDC tl.2, ata.) <br />Project Contact & Telephone # <br />_jy� / Phone <br />/ Aff/; ?G V <br />Tank Size <br />Phone # <br />Phone # <br />CA Lic# <br />Work Comp # <br />Expiration pate <br />Explratlon Bate <br />Chemicals Stored Currently <br />P L ApprovedApproved with conditions ❑ Disapproved <br />I. (See®Attachment With Conditions) <br />A n; <br />s <br />N Plan Reviewers Name---A,Date <br />Date UST <br />Installed <br />�UCANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />kQUIN COUNTY, ENVIRONMENTAI. HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />'PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUWI:CT TO <br />RKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURr_ CPRTIFIF$ TI -IE FOLLOWING: "I CERTIFY <br />kT IN THE PERFORMANCE- OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUEJF rT TO WORKER'S COMPENSATION LAWS <br />CALIFORNIA." <br />TRIA Date Lt k'1 L f <br />BILLING INFORMATION' <br />Indicate the responsible party to be billed for additional EFID 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 />NAME �.�f V -116l r� (F—r TITLE PHONE <br />S <br />EH230038 (rafted 0811/1 <br />A <br />-f� `�--i 4�,-Z-4-0 <br />TF_ tc f (rjt� <br />