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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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT ❑PIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# GE6 510 –4155 <br /> A <br /> C Facility Name 0010,6 5-18P Phone# 591- 4261 <br /> I Address <br /> L <br /> TCross Street <br /> Y Owner/Operator Phone# <br /> C <br /> Q Contractor NameEliki-aPhone# <br /> N <br /> T Contractor Address= CA Lic# WAD Class <br /> wh PV <br /> A Insurer ` Work Comp# ®6 <br /> C ICC Technician's Name <br /> T Expiration Date <br /> ICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Date UST <br /> (.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Tank Size Chemicals Stored Currently <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name t 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 AGENT'S 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: "I 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 /> Applicant's Signature TRIe Data 21Y2- <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 /> responsibility for the billing by signature and date below. <br /> NAME URE.II1- c1�1TR� Tt fZ. It <br /> -"Cj TITLPHONE#_ <br /> ADDRESS 21� 1(1 '` �Y a �� T� �r 95'2 ffi <br /> L2— <br /> SIGNATURE ) DATE o4, '_('.) <br /> EH230038(revised 08/1/11) <br /> 2 <br />