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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 /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#,�(,�� <br /> A <br /> G Facility Name <br /> Address <br /> L I �� '� Li <br /> TCross Street <br /> Y Owner/Operator fnahl"lu Phone# g <br /> oContractor Name Phone# <br /> N Mt <br /> Contractor Address /_ , Q <br /> T % ' '� CA Lic# Imo/ Class <br /> R Insurer bbol u y-k(, Work Comp# <br /> C ' <br /> ICC Technicians Name <br /> T Expiration Date <br /> oICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,ueny <br /> oC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved �154pproved with conditions ❑ Disapproved <br /> L (S Attachme t With Conditions) <br /> A CA4 <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WO KIN ACCOR CE WI SAN JOAQ N UNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LI NSED 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 PERFORM CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> � �CfCe� , <br /> Appl(cant's Signature Title a 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 /> r. <br /> NAME l(�.rnt'i// /� /� TITLE_1�, �FJ �f 1�l1�P�'' PHONE <br /> ADDRESS <br /> SIGNATURE 4 DATE <br /> EH230038(revised 08/1/11) <br /> 2 <br />