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SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Tdephone, (209) 468-3420 Fax: (209) 468-34-33 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFff OR PWWG REPAIR FIER4VWT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICA7 E PERMIT TYPE BELOW: <br />D TANK RETROFIT 5 PIPING REPAIRIRETROFIT P UDC REPAIR/RETROFIT F] COLD START/EVR UPGRADE <br />F <br />A <br />t. <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />I.R <br />I <br />A <br />N <br />K <br />FRA Site Project Contact & Telephone <br /># <br />;7soility Name- <br />Acdress <br />Cr -.,ss Stree- <br />Or/ner/Operator Phone <br />C(:ntractor Name Phone# <br />Z1,6,& Class <br />_441' _S� Lic# 7y <br />CcntrFctor Address <br />Work Comp <br />IC:, Technician's Name P F�fjw'- Expiration Date .5! /ZC' <br />Expiration Date <br />:C � installe,-'s Name _7 <br />Tank system work area Tank Size I Chemicals Stored Currently <br />(I.(., a'/ ppwq st'llip. 01 Iuak u(stector. u0c I2. eic,) <br />ae <br />Installet <br />I I Apl: oved Approved with conditions Disapproved <br />L (Se ... achment With Conditions) <br />A <br />g <br />I V <br />N <br />jkPlan Reviewers Name Date <br />APPLICAt T MUST rC--.:-.FOHM All WORK IN ACCORDANCE. WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS. AND RULES AND RCGLjLA rioNS OF SAN <br />.JOAQUIN COUNTY, I,%IVIRONMr-.NTAL I IEALTH DEPARTMENT, OWNER OR LICENSCD AGENT'S SIGNATURE CERTIFIES THE FOH.OWING: "I CERT IFY THAT IN <br />THE PFRrORIVIANC17 OF TI IE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS'ro:3ECOME sU3JFCT <br />TO WORKER'S COMPS:NSATION I AWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THEI FOLLOWING: "I CERTIFY <br />THAT IN I HE PERFORNMANCE OI 'THE WORK FOR WHICH THIS PERMIT' IS ISSUED. I SHALL EMPI.OY PERSONS SUBJECT TO WORKF LAWS <br />OF CAI I:!)RNIA," <br />Applicant':; Signature_._ <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage par 'tank. If <br />the par.y designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />respons'bility for the billing by signature and date below. <br />NAME..-__.- <br />ADORE' <br />SIGNATURF.___.. _ <br />E%:2300:3 (revised 2/20/09) <br />1. <br />. PHONE#, ._ <br />. I -DATE <br />