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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 PERMITTYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />C <br />Facility Name <br />Phone # <br />I <br />L <br />Address <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # - g <br />C <br />o <br />Contractor Name <br />Phone # - <br />N <br />r <br />Contractor Address - <br />CA Lic # Class <br />AInsurer <br />s <br />Work Comp # <br />T <br />ICC Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Q.e. 87 piping sump, 91 leak detector, UDC 112, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved r K Approved With conditions ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name _ _ Rate _ _ _. .. /. _ 0 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE CNITH SAN JOAQUINOUNTY 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=MPENSATIOTr-LAWS OF 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION.LAWS_ <br />OrOWFORNIA:" <br />Applicants Signature Tdle Datejai=G I J 1 <br />BILLING INFORMATION: <br />ffil <br />n <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 />res onsiblll for the billin b - sI nature and date below. <br />NAME I:{'�- LU ntlM�czrQ. /Mb elm TITLE {Lt(F) -PHONE # 266 "+'bj-6 j <br />ADDRESS ' }J WVI( i htNf, rr p qs <br />SIGNATURE DATE 1 ` V1 -L V�1) <br />EH230038,(revis@d 08/1/11) <br />{ <br />t <br />1. , 1�1 Y'�� tr �.{! i , { {t1 I#�t;� �{� i 1 ' ,�J ♦'4+#�'d <br />1 <br />