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ENVIRON ENTAL 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 REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F �FaCici <br /> PA Site# Project Contact&Telephone# <br /> A <br /> C lity Name Phone# y <br /> L Address <br /> TCross Street <br /> Y Owner/OperatorDeb Phone# _ <br /> C Contractor NamePhone# <br /> 0 -2iN !946 65.10 <br /> N <br /> T Contractor Address CA Lic# Class <br /> wt <br /> R Insurer <br /> A Work Comp# <br /> c ICC Technician's Name <br /> T Expiration Date <br /> oICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Date UST <br /> (i.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 ❑ ApprovedApproved with conditions ❑ Disapproved <br /> L <br /> A (See ttachment With Conditions) <br /> 7 r <br /> N Plan Reviewers Name Date / 1 <br /> APPLICANT-MUST PERFORM ALL WORK 1N 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 WORKEFJ'SCOMPENSATION LAWS <br /> 01=CALIFORNIA <br /> Applicant's Signature Title Date <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 U of U T( ,S NC�C�4 1��TIWkTL �e <br /> �j�✓��✓ y� �/�—PHONE# GLJ 1 �lld' lQ � <br /> ADDRESS 25Et)_ (ILV1l�'d�1 �f�L�( � �T(J�Y. n r 1� _ 16gbfi <br /> SIGNATURE t,� DATE S 1 l <br /> � <br /> EH230038(revised 08/1/11) <br /> 2 <br />