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0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 Fast 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 />JTANK RETROFIT L _1PIPING REPAIR/RETROFIT F IUDC REPAIR/RETROFIT I - ]COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />O <br />Facility Name _ <br />Phone# pC/-g30-qci <br />� <br />Address <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # X12 �Lt(D-) <br />C <br />Contractor Name k p 4 n �� <br />Phone # 2Ori- ZkG -12-4 G <br />T <br />Contractor Address I t p W yE1Z I it M"(q. qS z4o <br />CA Lic # ') y 3 b o Class <br />RInsurer <br />A <br />�(LA.,4IL(Aj5tgL &,.,, <br />Work Comp # <br />TICC <br />T <br />Technician's Certification Number S Itw VJ) LI e*%c> SO ► 1,04-7-(�% <br />Expiration Date l0 -I 7�U 1� <br />D <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />roved with conditions I__bisapproved <br />[]Approv ad %Aichment <br />L <br />A <br />e With Conditions) <br />N <br />Plan Reviewers Name Date (/I <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOA IN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JCAOUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS 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 TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THATIN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicants Signature Title Date <br />BILLING INFORMATION: <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 TITLE PHONE # <br />SIGNATURE <br />EH230038 (revised 12/31/07) <br />1 <br />