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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East 1Vi=Street,Stockton,Cal fornix 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 PERMITsfyPE BELOW: <br /> DTANK RETROFrr DPIPING REPAIRPZMOFrr DU <br /> DC REPAIR/RETROFrr COLD sTART/EVR UPGRADE. <br /> A EPA Site# Project Contact&Telephone# — <br /> C Facility Name Q Phone# <br /> Address <br /> a <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator R _ <br /> � Phone# <br /> 0Contractor Name <br /> D ��Z Phone# <br /> N <br /> T Contractor Address 22 <br /> —� - <br /> CA tic# ClassR Insurer In HWA <br /> AXp(f� Work Comp#top _Q <br /> T !CC Technician's Certification Number <br /> D Expiration Date <br /> R ICC 1nstaIIws Certification Number Expiration Date <br /> Tank ID# Ta�Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P DApproved "gApproved with conditions DDisapproved <br /> A ( chment With Conditions). /) <br /> N Plan Reviewers Name <br /> Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE 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 TO <br /> WORKERS COMPENSATION LAWS OF CALIFORNIA.• CONTRACTORS 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 WORKERS COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> Applicants SignatureTide ` <br /> Date � 1 <br /> BILLING IN RMATION: - <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 /> responsibility for the billing by signature and date below. fig" ~� <br /> NAME Tt71E (C�f�l PHONE# <br /> ADDRESS L.I J t ^I t o}m o?\I f/ <br /> SIGNATURE 1\ I <br /> EH230038(revised 12(31/07) <br /> 1 <br />