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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 REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site #(-A [_- a� d �' <br />Project Contact & Telephone # �3 <br />C <br />Facility Name-_ <br />�� <br />Phone ,,y6 .- <br />Address 7 t,) �- <br />7- 7 TI�Ct (!!4S� <br />T <br />Cross Street K <br />`1 <br />Y <br />Owner/Operator <br />Phone � <br />C <br />Contractor Name :D70 " <br />Phone # s -1/ <br />TContractor <br />Address -,L <br />CA Lic #773 S� Class /h , <br />RInsurer <br />A <br />Work Comp # <br />T <br />ICC Technician's Name �%� <br />Expiration Date <br />DICC <br />R <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />8 ( 0" <br />T <br />l <br />A <br />N <br />K <br />P <br />❑ Approved <br />'Approved with conditions ❑ Disapproved <br />L <br />A <br />See Attachment With Conditions) <br />N <br />Plan Reviewers Na <br />C % e <br />Date <br />APPLICANT <br />MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN <br />COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OFT 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 COMPENSA N LAWS OF CALIFORNIA." CONTRACT 'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANC OF THE WORK FOR WHICH THIS P IT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature <br />/� L/�4p <br />Title v /t' ,— — t— 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 <br />/ billing by signaatt'ure and /date below. j�� / � � 7i�� <br />NAMIE F,A \1��H 5;6Z�0 TITLE �../WJV`��— PHONED -6, -C\� `- ; [fl'\ <br />ADDRESS [ G b i 2 !� pe --A q Js K <br />SIGNATURE <br />EH230038 (revised 02/20/09) <br />1 <br />