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• <br />0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <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 1130 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />D TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # Y�l m <br />Facility Name C(� <br />Phone # <br />IAddress <br />L <br />ib <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator <br />Phone # (}C <br />Name <br />Phone # -(Q <br />oContractor <br />EU <br />N <br />T <br />Contractor Address <br />CA Lic # <br />�G Class <br />Insurer ° <br />Work Comp # . ' 1 I `J <br />_ <br />C <br />T <br />ICC Technician's Name <br />Expiration Date <br />o <br />R <br />IGC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 67 piping sump, 91 leak detector, UDC 112, etc,) <br />T <br />A <br />N <br />K <br />P <br />❑ Approv d <br />Approved with conditions Dioved <br />L <br />At achment With Conditions) <br />A <br />ge <br />Wa <br />N <br />Plan Reviewers Name <br />Date <br />PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUt CUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />4QUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A5 TO BECOME SUBJECT TO <br />?RKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRENG OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />AT 6N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />CALIFORNIA." <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 />respons�ib(ility for <br />lthe <br />�4bilfsng by signature and date below. ]. �5 ��I� ` f" r� <br />NAME f \J {o 1�f41� kj l,.L-.t i a � TITLE�� Qf �?l'.�i�il TT Vt j PHONE # P { �[0 1 +C[ 5- 1 <br />ADDRESS��,�11 �t�)lI� I]1-� `�+✓ ST fiA 1.� <br />SIGNATURE IJ61C DATE O C 1L 1 <br />EH230038 (revised 07-17-2014) <br />