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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 /> ®,TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A (-( _ 3 <br /> D Facility Name Qu Phone# 4_ �'3(a_ a q6 <br /> Address <br /> T Cross Street i _ oLOS <br /> Y Owner/Operator Phone# <br /> o Contractor Name ��, �j-t-�-t ,� s�� 5 ��� Phone# <br /> T Contractor Address 00 Qu P.. � A TWQ- CA Lic# <br /> R �{•S'SI$y- Class� l iG AZ- <br /> A InsurerY. :XFt Work Comp# I ©�©63��e <br /> TICC Technicians Name <br /> T ' -30". lOL.�,'t{'' Expiration Date • -arc(3 p <br /> DICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Appr ed pproved with conditions ElDisapproved <br /> L <br /> A ( e Attachment With Conditions) W-1N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STAT 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 /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'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 WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ' �L L title A tdLlCQ 040CR /Applicant's SignaturejcC� a >L � BILLING INFORMATION: Date <br /> ha = <br /> q <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. �[' - / <br /> NAME �Q- � �1 �/ .�1A.� �LI/� TITLE �C11l.tebUC�1�C'� 6g4C-�C/` PHONE# �`c'-Ia —�03 0Q <br /> ADDRESS CAV- 1� I �. <br /> SIGNATURE �l'L� :>.Z L•i� L/ , Cf� t L-Li.�,c�'� DATE -T /(qC01po <br /> EH230038(revised 02/20/09) <br /> 1 <br />