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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 TY W90t4VMRT/EVR UPGRADE <br />El TANK RETROFIT ❑PIPING REPA <br />IRIRETROFIT El UDC REPAIR/RETROFIT <br />F I EPA Site # <br />A FacilityMN� l�(� ��CIAddres0. -�tXLI Cross T <br />Y OwnercContraO <br />N ContraQ <br />T <br />R Insurer (` <br />A <br />C ICC Technician's Name <br />T <br />o <br />R ICC Installer's Name ((S C <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />T rT! <br />A <br />N <br />K <br />P ❑ Approved <br />L <br />A <br />N Plan Reviewers Name <br />Project Contact & Telephone # <br />Tank Size <br />CA Lic # <br />Phone # <br />Phone # Z,p cj 14(ot> <br />Phone # <br />Work Comp # b <br />Expiration Date_ <br />Expiration Date ,� h <br />Chemicals Stored Currently <br />`K Approved with conditions <br />(See Attachment Wi Conditions) <br />/" � _ D <br />11 <br />to <br />❑ Disapproved <br />?A <br />imm <br />Date UST <br />Installed <br />GULATIONS <br />APPLICANTTY, ENV RONMEN AOL HEALTHCDEPARTMENT. OWNER OROLICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGORDANCE WITH SAN JOAUIN COLIN RDINANCES, STATE LAWS, AND RULES AND : "I O <br />I CERTIIFY THAT IN <br />F SAN <br />FOR WHICH THIS JOAQUIN COUNTY,NOT EMPLOY AY <br />AS TO BECOME SUBJECT <br />THE PERFORMANMPENS HE W L SOF CAL TORN AP CONTRACTOR'S HIRING OR SUBCONTR CNTING PERSON IN S GNATURE CERT F ES THE FOLLOWING: " CERTIFY <br />TO WORKER'S <br />O NCE THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TOS <br />(WORKER' <br />THAT IN THE PE COMPENSATION LAW <br />OF CALIFORNIA." I / I—_ A <br />fftimeexpendete permit payment tank. <br />Indicate the resp rty o be billed for additional EHD stabeyond <br />party mut acknowledge <br />the party designated is different than the permit applicant, g. property <br />responsibility for the billing by signature and date below. <br />TITLE PHONE # <br />NAME <br />SIGNATUF <br />EH230038 <br />1 <br />TE 3-( -ID <br />02.- <br />