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ENVIRONMINTAL 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 ❑PIPING REPAIR/RETROFIT ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRAD - <br /> F EPA Site# Project Contact&Telephone# <br /> A Facility Name Pn e# 0`10 75- 0 <br /> I Address 1 <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone �jyn,L, <br /> G Contractor Name Phone# <br /> - ' — _. <br /> TContractor Address CA Lie# Class <br /> R Insurer Work Comp# <br /> A <br /> T ]CC Technician's Name... --Expiration Date - - <br /> o <br /> R ICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> 0.e.87 piping sump.91 leak dste=r.UDC 12,e[c) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved �pproved with conditions ❑ Disapproved <br /> L (See ment Wdh Conditions) <br /> A - l <br /> N _ <br /> Plan Reviewers Name Date 7 <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 EMPLOYANYPERSON INSUCHA-MANNER AS TO-BECOME-SUBJECT. <br /> TO WORKER'S COM ION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFOR C OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CAUFORNIA." <br /> L 1 1. Date <br /> Applimnl's Signature Tide <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank If the party designated below is different than the permit applicant, e.g. property owner,the party must acknowledge <br /> this re nsibility for the billing by signature and date befow. <br /> NAM"4'11JI ( __ TITLE /" J`99 <br /> dllgA PHONE#- 4W /l2JJl <br /> ADDRESS <br /> SIGNATURE DATE Ii <br /> EH230038(revised 07/22/10) <br /> 2 <br />