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ENVIRO ENTAL HEALTH D RTMENT <br /> SAN JOAQUIN COUN <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# <br /> A <br /> O Facility Name4' Phone# <br /> L Address <br /> L6 <br /> TCross Street <br /> Y Owner/Operator Phone# <br /> C Contractor Name Phone# _ <br /> N <br /> T Contractor Address Un CA Lic# Class <br /> � <br /> R Insurer <br /> A Work Comp# <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 /> (i.e.87 piping sump,91 leak detector,UDc 1/2,etc.) Tank Size Chemicals Stored Currently Installed <br /> T <br /> A <br /> N <br /> K <br /> P El Approved A proved with conditions El Disapproved <br /> L A ment With Conditions) - <br /> A <br /> N Plan Reviewers Name Date <br /> — - - <br /> PPLICANTIGIUST'PERFORR717CC1 WORKIN ACCORDANCE WITR SAN JOAQUIN COUNTY ORDINANCE§,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 /> HE.PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A$TO BECOME S_UBJECTTO __-,________ <br /> WORKERS CIJh71PEIV5ATt0 �VS OF CALIFOIA CONTfA�TOR'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 WORKE,. S ION LAWS <br /> OF`CALIFORNIA - <br /> . . <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. 1f <br /> the,party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> n <br /> i <br /> r the <br /> responsibility for bllig_by signature and below. <br /> _--- " _ _, <br /> NAME ��`-[E (� � T(YZ5I CMCJ TITLEPHONE# L U"1 'jjQI- <br /> ADDRESS �L l�1� 1,8 K�N�� G�� C ` 266 <br /> SIGNATURE_*Z C j,� DATE lA <br /> EH230038(revised 08/1/11) <br /> 2 <br />