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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOA+QUIN 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 N COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A A <br /> G Facility Name - Phone <br /> IAddress <br /> L <br /> T Cross Street r7 <br /> Y Owner perat Q 71 Phone# C <br /> c Contractor Name NL Phone# � ( � <br /> D <br /> N Contractor Address CA Lic# -3Q�-J tl Class A <br /> AInsurer C Work Comp# c.) 75�{ -0 <br /> C ICC Technician's Name <br /> T -� Expiration Date 1 —� <br /> R ICC Installer's Name r <br /> �� 1� J�--C�(�J-. Expiration Date <br /> Tank system work area Tank Size Chemicals Stared Currently Date UST <br /> (Le.87 piping sump,91 leak detector,JDC 112,etc.} Y Installed <br /> T 1 <br /> A I <br /> N <br /> K <br /> P pproved Approved with conditions El Disapproved <br /> ee Attachment With Conditi:�a-te�-' <br /> A 1 �It_ <br /> N Plan Reviewers Name <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 <br /> TO WORKER'S COMPENSATION LAWS OF C NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF TH K FOR WHICH T IS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature Title Date T b <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 /> NAME ? ccn n TITLE e-r PHONE# c q <br /> ADDRESS— J ' Q <br /> SIGNATURE DATE 0 <br /> EH230038(revised 0212010 <br /> i <br />