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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 REPAIRIRETROFITXCOLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # p,�}�pQ� (2oq)40q( 32 <br />Facility Name S L - - 5 Phone # <br />Address l ST <br />T <br />Cross StreetI <br />Y <br />Owner/Operator �p-,e � ,^ Phone#oda- (0 <br />C <br />Contractor Name e� e Q y �,{ S e <br />Phone # Zpck _ �l(5- & (p <br />0 <br />�}Qril,,� • <br />NContractor <br />Address S2� ��-qr>� S� <br />CALic# <br />Class <br />_ <br />AInsurer <br />C U tom, „�% <br />Work Comp # <br />T <br />ICC Technician's Name C U Z <br />Expiration Date L4 - 3p -2) t 1 <br />R <br />ICC Installer's Name v S Z <br />Expiration Date (-- (5 - go ti 1 <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />A <br />N <br />ttachment With Conditions) <br />Name Date 7 <br />Plan Reviewers <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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFO NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." !/� /� }�/ /n'� <br />/4 UIli"""— (12`11 2 Z0 �o <br />Applicant's Signature r[ � 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 />responsibil� for the billing by signature and date below. <br />NAME jaC -DO-Q-tj kA TITLE w�P�L PHONE #_ �IOV ' (001 <br />nnnRFcc -71 7 (A—) • \.� S�• t <br />SIGNATURE Jc� � <br />EH230038 (revised 02/20/09) <br />1 <br />TE (0 L21 L20 / Q <br />