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Ir <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 />El TANK.RETROFIT,❑ PIPING REPAIR/RETROFIT ❑UDC REP_ AIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />A EPA Site # Project Contact & Telephone # I� <br />C Facility Name . <br />t. Phone It <br />Address Ol;"„S�('i1 . <br />T. <br />Cross Street <br />Y.Owner/Operator \ r <br />C Phone#'�- <br />D Contractor. -Name <br />N Phone.# _ <br />T Contractor Address <br />R tt��r►i�% ��. A IPsur� Irc # I Class . O <br />A <br />C � _ � � _ Work Comp t, SG (� •) <br />T ICC Technician's NameC)) <br />(yC?�(M, Expiration Date <br />R ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />p -e. az piping -Mp. 91 leak deWctor. UDC 12. em l Tank Size Chemicals Stored Currently Date :UST <br />installed <br />T <br />A <br />N <br />K <br />rApplicatirs <br />❑ Approved <br />pproved with conditions ❑ Disapproved <br />See <br />( Attachment With Conditions) <br />lan Reviewers Name <br />Date <br />NT MUST PERFORM ALL WORK iN ACCORDANCE WITH 5AN JOAQUIN..000NTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR iICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT,_IN. <br />FORMANCE.OFTk{E �yDRKFOR:WHICH-THIS PERMIT 15 ISSUED I SHALL NOT EMPLOI^gNYpER501V IN SUCH A7GANNER A$ TO`9ECOME SUBJECT <br />EE PER MPENSATION L AWS OF: CXLIFORNIA' ,CONTRACTOR'S HIRING oR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br />HEPERFQRMANCE OF THE WORK FOR WHICH THIS PERMITlS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAW$ <br />RNIA.' n <br />SignatuX�JA ` Title <br />Date <br />BILLING INFORMATION: <br />Indicatethe responsible party to be billed for additional EHD-staff Time expended beyond permit payment coverage per tank. f <br />the_..party designated below is different than the <br />- - - pe[mii.,appiicant; . e.g. property owner, the party, must_ acknowledge this <br />responsibility for the blllirig by signature and date'below. <br />NAME <br />TITLE 1 TI L I _yin <br />_l <br />__L_PHONE <br />ADDRESS <br />SIGNATURE <br />O <br />EH2DATE <br />30038 (revised 02/20/09) - <br />1 - <br />