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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 <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> -THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> oAddress <br /> Site# Project Contact&Telephone# �1 <br /> ame �' FOE) <br /> reet peratorPhone <br /> r Name - - Phone# <br /> N ContractorAddress - <br /> T CA LID# <br /> R Insurer Class <br /> A < Work Comp# _ <br /> T ICC Technician's Name - <br /> Expiration Date <br /> . . _R ._....ICC Installer's Nama . _... . Expiration Date __-- <br /> Tank system work area- . <br /> 0.9.87 PIPLi9 Sump,911eek delectm,UDC U2,et&) Tank Size Chemicals Stored Currently DateLIST <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> 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 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 Or 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 /> Applicant's Signature Title <br /> Date <br /> BILLING INFORMATION: <br /> Indicate the responsibleparty 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 ,tYnIt 1 slow. <br /> � <br /> NAME E..1 tTE.CU C�I(�TR� T`Qcj r�"p 1 TIT LE�P�('Q.Yl�9l' ����). PHONE#�'_r(oI�0 1,7� <br /> ADDRESS 76?, (1)1i1L�'�\.Io IZIV \(i 1�I I r(%n q 2(� <br /> SIGNATURE- `Tv an (14ii ir) DATE. <br /> EH230038(revised 08/1/11) - <br />