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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 ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />O <br />,— <br />Facility Name C <br />-c 11 <br />Phone # - "8 A <br />IAddress <br />9 <br />L <br />TCross <br />Street ` <br />I <br />_ <br />Y <br />Owner/Operator <br />Phone - <br />c <br />0 <br />Contractor NameRZ ��(l <br />a <br />Phone # <br />TContractor <br />Address (0.2C <br />CA Lic #� '� �� � Class -- <br />A <br />Insurer � L <br />Work Comp <br />TICC <br />Technician's Name]` <br />m� <br />Expiration Date <br />RICC <br />Installer's Name m ,- <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved <br />Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />N <br />-I ��-09 <br />Plan Reviewers Name <br />V/� I.JT"Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />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 <br />TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br />THAT <br />IN THE PERFORMANCE OF THEW RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />t <br />Applicant's Signature,'- <br />Tit] Date % <br />BILLING INFURMAWN: <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. �s <br />--- N -di -I- .... .._- --• -TITLENAME- PHONE # �� G J Z % S��✓3 <br />ADDRESS 640 S G(exyl <br />SIGNATURE[ <br />EH230038 (revised 02/20/09) <br />CA t/T- <br />1 <br />DATE -1--,2, C o <br />