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ENVIRONMENTAL <br />SAN <br />JOAQUIN <br />60East Main Street, Stockton, Califomis 95202 <br />0 <br />1' 468-3420 I9468-3433 <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 />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAI ETROFIT ❑ COLD START/EVR UPGRADE <br />a <br />i +i n <br />I -C % . <br />Tank m work area <br />p.e. 87 plph sump, I leak d6I UDC W. M) <br />_.- ::.,. <br />Tank Size <br />9 <br />P ® Approved <br />L <br />A <br />N Plan Reviewers Name <br />►.i — =' <br />[EMIHEN <br />s <br />Disapproved <br />APPLICANT MUST PERFORM ALL WORK IN AC R E WITH SAN JOAQUIN COUNTY D NCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DE ARTMENT. OWNER OR LICENSED AGE S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE 0® WORKER'S COMPEF THE WORK FOR NSATION LAWS OF CAL CALIFOICH THIS NER AS To BECOME SUBJECT <br />RNIA." CONTRACTOERMIT IS UR'S HIRING OR SUBCONTRACTING SIGNATURE, CERTII SHALL NOT EMPLOY ANY PERSON IN SUCH A FIES THE FOLLOWING: CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHI H THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S CO ENSATION LAWS <br />OF CALIFORNIA" Dai <br />��'1- �� `�' <br />Indicate the responsible party to be billed for additional EMD staff time expended beyond permit payment <br />the <br />�vust acknoredge this <br />the party designated below is different than the permit applicant, e.g. property owner, the party <br />responsibility for the billing by signature and date below. <br />TI0PHONE # <br />SIGNATURE <br />(revs <br />EH230038 02120109) <br />