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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUM 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 REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name ( Phone# <br /> Address y <br /> T <br /> Cross Street L4 0 <br /> Y Owner/Operator f. Phone# „ <br /> o Contractor Name TPOGj Phone# _ <br /> T CTC Contractor Address A Lic# _ (�1 <br /> Class <br /> CA <br /> C Work Comp# d91 7 00 <br /> A Insurer <br /> C ]CC Technician's Name �C <br /> T Expiration Date <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Cate UST <br /> (i.e.87 piping sump,91 leak delector,LIDC 12,ele.) - y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approv d Approved with conditions ❑ Disapproved <br /> L <br /> A (Se Attachment WI Conditions) <br /> 4 � <br /> N Plan Reviewers Name <br /> -Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOA©UIN 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 /> 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 /> TOVORKER'S COMPENSATION 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,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Appficant's Signature_ Title <br /> 1 <br /> �+� 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 /> NAME I k)_13L ea ;_ TITLE_ , TI� PRUNE <br /> ADDRESS MA �51L 10P . 9 20 t - <br /> SIGNATURE_ DATE �� ! <br /> EH230038(revised 02120/09) <br /> 1 <br />