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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 /> D TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 6>, <br /> C Facility Name rC h [ _. Phone# - <br /> Address v <br /> I Cross Street <br /> T <br /> Y Owner/Operator hnyomPhone <br /> o Contractor Name Phone# <br /> N <br /> T Contractor Address CA Lic# Class <br /> AVjj <br /> A Insurer < Work Comp# <br /> DICC Technician's Name "v <br /> T Expiration Date <br /> o ICC Installer's Name <br /> R � Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently <br /> Date UST <br /> (i.e.aT Piping sumo,e1 leak deleaar,uoc in,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P El Approved )&pproved With conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date_ aal V/ <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 /> WORKERSCOMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 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 /> Iiptlaanl's Signa lure TRIe 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 /> responsibility for the billing by signature and date below. <br /> -_ CtYY1WITLE n ('( 9(�-( 'A�I <br /> NAME E..,�t-[F.C�I CCI("1TRIa 7t�(L.S rrC� TITLE �rP���.,Yl�11 �r��1C )�lCn�Pr-H�ONE# 2C}'I 0 hr <br /> ADDRESS 7s�f K 1 \J" JY�'(T� q%jN_ I,�S:aVi `'�ULIS ) <br /> SIGNATURE 13M (_�,�L � DATE <br /> EH230038(revised 08/1/11) <br /> 2 <br />