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ENVIRONMEi4TAL HEALTH DEKARTMENT <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 /> n. THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> PTANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A _ <br /> O Facility Name TY A P Y' Yic . Phone# — ) 2. <br /> � Address tuc <br /> T Cross Street c G r <br /> Y Owner/Operator YU t Phone# y- <br /> oContractor Name v _ m Phone# _ bL <br /> N Contractor Address <br /> T CA Lic# Class <br /> R Insurer <br /> A Work Comp# <br /> DICC Technician's Certification Number <br /> T Expiration Date <br /> QICC Installer's Certification Number <br /> R Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved ❑Approved with conditions ❑Disapproved <br /> L <br /> A (See Attachment With Conditions) <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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE CK 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 " � ywr•�� Date Q Q <br /> BILLING INFORMA ION: <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 'l (A V u1 Vol // TITLE U L7 bf y"""'-r S PHONE# I � ' �— D G <br /> g� <br /> ADDRESS 7�of N 117a ( IT/7 A el 4?y/ <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />