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� r � <br />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 El PIPING REPAIRIRETROFITJDC REPAIR/RETROFIT ElCOLD STARTIEVR UPGRADE <br />A EPA Site # Project Contact & Telephone # <br />C Facility Name <br />Address Phor►e <br />t Cross Street <br />T <br />Y Owner/Operator <br />Phone # <br />G C <br />N ontractor Name <br />i Phone # f <br />N Contractor Address <br />T CA Lic #� <br />R 1rasUrr E-1 �{� y� fy s� (� <br />A 1 3 F'Y1 ►�tt. T <br />C �-�� 1 Work Comp � >� <br />T ICC Technician's Name <br />o �..1 �L (7� O1 <br />�,1 ��L� Expiration Date <br />R ICC Installer's Name1 <br />�- Expiration Date <br />Tank system "work area Q ]� <br />fl -e- 87 pipingsnmp, 91 leak delactor, UDC 11Z etc,l ank Size Chemicals Stored Currently <br />T <br />A <br />N <br />K <br />Class <br />JP ❑ Approved — <br />NJ <br />with conditions ❑ Disapproved <br />A (See Attachment With Conditions) <br />N Plan Reviewers Name <br />to <br />Date UST <br />installed <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />TO- OPERFORMANCEEOF THE WORK FOR-WHIGH-TH15.PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY'PERSON IN SUCH A_MANNER AS TDI CERTIE SUBJECT <br />TOWORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT 1N Ti iE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrr IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WDRKER`S COMPENSATION LAWS <br />OF CALIFORNIA.` <br />Applicants Signature - Title h TirC <br />lJ Date <br />BILLING INFORMATION: <br />Indicate the responsible party to tae billed for additional EHD staff time expended beyond permit payment coverage per tank. if <br />the party designated below is different than thepermit applicant, e.g. property owner, the party roust_ acknowledge this <br />responsibility for the billing by signature and date below. ! <br />NAM CQL.[VL_—TITLE PHONE {i1� <br />SIGNATURE k 1�`� <br />�--' <br />EH230038 (r6ised 02/20/o9) - <br />1 <br />