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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, 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 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW. <br />TANK RETROFIT UPIPING REPAIRIRETROFIT -n UUDC REPAIRIRETROFIT <br />F <br />EPA Site # Project Contact & Telephone # r <br />A <br />C <br />Facility NamePhone <br /># -� <br />1 <br />L <br />Address <br />1 <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # lJV //���� Q^ <br />U w�. <br />C <br />Contractor Name <br />Phone # <br />190C10 <br />T <br />Contracto Address <br />CA Lic # Cla <br />R <br />Insurer <br />Work Comp #P6 <br />A <br />T <br />T <br />ICC Technician's Certification Number — <br />Expiration Date 00-7 <br />RICC <br />installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Date UST Installed <br />Currently/Previously <br />T <br />A <br />N <br />K <br />UApproved UDisapproved <br />P <br />Approved with conditions <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Pian Reviewers Name Date s <br />APPLICANT MUST PERFORM ALL WORK_ W 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 FOLLCV41NG: "I CERTIFY THAT IN <br />THE PERFORMANCE WORK FOR WHIq I THIS PERMfT IS R%SUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKERS COMPEN TI LAWS OF CALIFORNIA." CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFTMA7E OF THE WORK FOR WHICH THIS PERMIT IS ; I SHALL EMPLM PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CAUFORNIA." <br />App1mrts SignntU <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 nt, e.g. props owner, the party must acknowledge this <br />respon 'bility or a billin signature and date below. <br />NAM TITLEappl' <br />SIGNATUR <br />EH230038 (revised 8/8/06) <br />1 <br />