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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 OPIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT OCOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name cz*V \-LSA"' <br />Phone # -IS-bo <br />L <br />Address <br />TCross <br />Street <br />Y <br />Owner/Operator ID VVN= <br />Phone # S 10 - (os -I_ c)n <br />o <br />Contractor Name Phone # G\(o _ 3-1a \.9-2g <br />T <br />Contractor Address - b - o p CA Lic # �"t, Class <br />AInsurer <br />r. <br />Work Comp # <br />TICC <br />Technician's Certification Number <br />Expiration Date <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />\ <br />kC` 41 <br />T <br />N <br />\d\A <br />Ck <br />K <br />e) <br />\e <br />P <br />ElApproved EiApproved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />I I <br />Date <br />Plan Reviewers Name %V1ri/�l�` a�%✓/t E- n / Gt ��I)A'' I C <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 />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFQRNIA." <br />II '1 ^1 p <br />Applicants SignatureLTitle \ - Date Lo - t " � O <br />BILLING INFORMATION: <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 />