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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 PERMIT TYPE BELOW: <br /> D TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone.#. ' <br /> -... ... A --___. _. .._. .. .t <br /> O Facility Name <br /> I cha Phone 4qq -I-1 <br /> L Address C <br /> I Cross Street r14 - <br /> y Owner/Operator <br /> Phone# <br /> C Contractor Name <br /> o Phone# <br /> T Contractor Address <br /> R CA Lic# Class <br /> A Insurer 19ria II`nQe - Work Comp# ` <br /> T ICC Technician's Name ' <br /> o Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (I.e.87pIpIn9snmp,91 leak deleda,UDC 112,elc) <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved Approved with conditions <br /> L ❑ Disapproved <br /> A Be Attachment With Conditions) <br /> N <br /> Plan Reviewers Name Date_120//3 <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 /> 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-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 SUB,JECTT TO WORKER'S COMPENSATION LAWS.. <br /> OF CALIFORNIA:' - - .. SUICT <br /> APPlicant's Signature Ll��tli�� Title I - -- --- <br /> �'l V(� Ott , <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_LI ITF.a L T% T .S INn J TITLE rtC PHONE# 26A 0I 0?fl <br /> .._. ADDRESS_. 2c l <br /> SIGNATURE—h= <br /> DATE_ L <br /> EH230038(revised 08/1/11) Nal <br /> e—� <br />