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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 /> 0 TANK RETROFIT D PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT D COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name 3 Phone# <br /> I Address <br /> L <br /> TCross Street <br /> Y Owner/Operator d - - Phone#ate. <br /> DContractor Name �. Phone# <br /> J09- �. !�'• <br /> 0 <br /> T Contractor Addre /t CA Lic# Class Q• Z, <br /> R Insurer t�-r�cg <br /> C Work Comp# .JL.[l <br /> T ICC Technici n's Name Expiration Date <br /> QICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak datectu,UDC IQ,eke) y Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> A // (Se Rachment With Conditions) <br /> N Plan Reviewers Naa(e Date �S <br /> G -- --__ <br /> APPLICANT MUST PERFORM 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 EMPLOYANY PERSON IN SUCH A MANNER.AS TO BECOME SUBJECTTO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORV4CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION.LAWS. <br /> Of CALIFORNIA." - ) _ <br /> Applkanfs Signature /rN" Tttle h a' 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 /> responsib"ty for the billing by signature <br /> signaj tur�eLand date below. <br /> NAME (Lno/1 TITLE��J04:RCE. <br /> IUWI�Q/TUPHONE <br /> I/tt,�F7-j <br /> /V Y2�37 <br /> ADDRESS G <br /> SIGNATURE <br /> _. _. <br /> EH230038(revised 08/1/11) <br /> 2 <br />