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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 />NK RETROFIT ❑ PIPING REPAIR/RETROFIT C❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />EPA Site # F <br />Facility Name <br />Address <br />Cross Street <br />Owner/Operator <br />Contractor Name <br />Contractor Address OIL <br />Insurer -}�,, <br />ICC Technician's Name <br />ICC Installer's Name <br />Tank system work area Ta. <br />(I.e. 87 piping sump. 91 leak detector. UDC 112, etc.) <br />❑ Approved <br />(See <br />Plan Reviewers Name <br />Toject Contact & Telephone 0. <br />CA Lic It <br />d� <br />Phone # <br />Phone # c �i(OJ �i t lel <br />Phone # cnq b j <br />w,ty(jl Class ( <br />Work Comp022. <br />Expiration Date <br />Expiration Date <br />Date UST <br />tk Size Chemicals Stored Currently Installed <br />Approved with conditions ❑ Disapproved <br />Attach nt With Conditions) <br />DateC r <br />TY ORDINANCES, STATE AND RULES AND RULATIONS OF SAN <br />IN ACCORDANCE <br />SAN <br />UIN <br />JOAQU NNCOMUST PERFORM ALLUNTY, ENV RONMENTTA�LRHEA HEALTH DEPARTMENT.rOWNER ORQLICENSED GENTS SIGNATURE CERTIFIES THE FOLLOWING:rI CERTIFY THAT IN <br />THE PERFORMANCE OF TH R WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WON THE PCOME CERTIFIES THE FOLLOWING: "I CERTIFY <br />P MANCE OFLAWS FRA FOR NI CHH CONTRACTOR T/S� SISUEDRING O SHAgCEM_PL'LOY PE SON SUBONTRACTING JECT TTO WO.RKE(R'S COMPENSATION LAWS <br />OFCALIFORN� t 1a�.c��_nXN�1) 1 I ..11 At<i� <br />Indic*�9) <br />nsibl to be billed for additional EHD staff time expeneeYondownere the paymentrmit rty must ack owedgetank. <br />this <br />the b i is different than the permit applicant, e.g. property <br />respbilling by ature and date below. rrn 62X-�1 XYZ <br />NAM <br />TITl� PHONE # <br />ADD�� �� (I ` IDATEI I rSIGEH2120 e9) <br />1� 1 <br />