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SAN JOAQUIN COUNTY <br />2 <br />9 9 <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 b4 COLD START/EVR UPGRADE <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />O <br />N <br />T <br />R <br />A <br />C <br />T <br />O <br />R <br />T <br />A <br />N <br />K <br />EPA Site # _ <br />Facility Name <br />AddressLL— <br />Cross Street <br />Owner/Operator 1 ®T <br />Contractor Name W 4i <br />Contractor Addressi ted �, <br />Insurer <br />ICC Techniciangt4hWe;\ <br />ICC Installer's Name <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />& Telephone # <br />Phone # <br />Phone # <br />Phone # <br />CA Lic # <br />Work Comp # E <br />Expiration Date <br />Expiration Date <br />Tank Size Chemicals Stored Currently <br />Class <br />Date UST <br />Installed <br />P ElApproved pproved with conditions ❑Disapproved <br />L e Aft h Conditions) <br />A <br />N Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE 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 COMPEN,9qION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PER A �THE WORK FOR WHICH THIS PERMIT I ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER COMPENSATION LAWS <br />OF CALIFORNIA." A 11& kv� i 14 <br />BILLING I <br />Indicate the responsible parry 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 />TITLE PHONE # <br />NAM% <br />sm <br />as <br />