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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 REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# VIL 441 <br /> D Facility Name + , ��. rar f 'Ap Phone# S <br /> � Address b ' 'fi <br /> TCross Street <br /> Y Owner/Operator �� `1 -T ` e( Phone# _ <br /> cContractor Name r <br /> o �{� � rl�Y tr✓�Zx'c, Phone# <br /> T Contractor Address J CA Lic# IPC()7 Class <br /> R <br /> A Insurer C� �, 1(,Work Comp# t5W3)G9-, <br /> T ICC Technician's Nam i')OL T aWExpiration Date <br /> ' <br /> ICC Installers Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current! Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> Plan Reviewers Name . 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 <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> THAT IN THE PERFORMANC QF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature �+ !� / D"f/UJI Title R l Date A11LI&I2t)ll <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the designated below is different than the permit applicant, e.g. property owner,the party must acknowledge <br /> this respon il' for the billing by signature and date below. 2 <br /> NAME ? �I �( � TITLE .7 1 ' Y PHONE# 4(/ n �/�(, i 337 <br /> ADDRESS 5�! ( j <br /> SIGNATURE UI-1 L ! <br /> DATE <br /> EH230038(revised 07/22110) <br /> 2 <br />