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. i- <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 PAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />F1 TANK RETROFIT El PIPING REPAIR/RETROFIT El4 <br />UDC REPAIR/RETROFIT COL START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # ® Q, C <br />� <br />Facility Name �Lj ® �"s <br />Phon <br />I <br />L <br />Address - <br />TCross <br />Street <br />Y <br />Owner/Operator �V- <br />Phone # t l <br />o <br />Contractor Name — ` <br />Phone # %5 -- " A' <br />T <br />Contractor Address <br />C is # d l Class <br />RC <br />Insurer <br />Work Comp # <br />A <br />T <br />ICC Technician's Name <br />Expiration Date <br />R <br />ICC Installer's Name `'` <br />Expiration Date L <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved ❑ Approved with conditions proved <br />L <br />(See Attachment With Conditions)--.,� <br />A <br />N <br />Plan Reviewers Name Date <br />DANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />APPLICANT MUST PERFORM ALL WORZHEALTH <br />JOAQUIN COUNTY, ENVIRONMENTAL PARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FTHIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWSRNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />\ ° 1'✓ Date <br />Applicant's Signature V Title <br />DILL111v 1111 Vr\IKlni 1W11 - <br />Indicate the respojbill�inb�ysignature <br />o be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designadifferent than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for thand date below. <br />ff <br />NAME V J TITLE l ��1��� PHONE`, up\ /N-,nLs i G '36C1 ' <br />�n�� <br />ADDRESS` V "` <br />SIGNATURE v DATE <br />EH230038 <br />1 <br />