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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, 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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT <br />❑PIPING RFPAIR/RFTRnFIT <br />F01 <br />F <br />A <br />EPA Site # Project Contact & Telephone #�l`C t �r� << �/S3 - 3 74 <br />C <br />/ <br />Facility Name Phone # tv z r -f <br />L <br />Address �rL& c _ <br />T <br />Cross Street <br />Y <br />Owner/Operator ( c'r 1 ��� �` <br />Phone # <br />C <br />o <br />Contractor Name <br />(�\r_ <br />Phone # <br />T <br />Contractor Address <br />Class <br />AInsurer <br />Work Comp # <br />cICC <br />T <br />i' <br />Technician's Certification Number <br />Expiration Date <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 />❑Approved Approved with conditions ❑Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers NameiDate (� <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 <br />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 />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." <br />Applicants Signature Title naso <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. I <br />NAME V��J l tut `Z �C�I C r cc TITLE PHONE #lt%k— <br />ADDRESS t4 - 4- k IL 1 co, 1{ Stec K t." C -o- l �-Zo 1 <br />SIGNATURE <br />EH230038 <br />1 <br />