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0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Teiephone: (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 REPAIRIRETRO!FIT 0 UDC REPAIRIRETROFIT ,VCOLD STARTIEVR UPGRADE <br />F l EPA Site # <br />A <br />C <br />'Facility Name Ckwr�,-� <br />IAddress <br />L <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator S <br />C <br />Contractor Name <br />O <br />N <br />Contractor Address <br />T <br />R <br />A <br />Insurer <br />TICC <br />Technician's Name�� <br />; <br />RICC <br />Installer's Name <br />n� f <br />Tank system work area <br />(Le. 87 piping sump, 91 leak detector, UDC 1J2, etc.) <br />T <br />A <br />N <br />K <br />P I ❑ Approved <br />L <br />A f <br />N Plan Reviewers Name,/ <br />Project Contact & Telephone # <br />r .r <br />Tank Size <br />Phone# --q3/--(/ <br />Phone # --) :�,? . -7 1�47 — <br />Phone # -'S <br />CA Lic # (? O <br />Work Comp # <br />Expiration Date <br />Expiration Date <br />Chemicals Stored Currently <br />---9t:J4pproved with conditions <br />(See Attachment With Conditions) <br />D ate <br />7247' t/8--( <br />Class , — L _Pyo <br />❑ Disapproved <br />Date UST <br />Installed <br />PPLICANT MUST PERFORM ALL W61K IN ACCORDANCE W;TH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />OAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />HE 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 />YORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />)F CALIFORNIA." <br />TitS�c7 .� 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 he billing by signature and date below. <br />NAME,� �aS--,Qn A - TITLE PHONE # 1 f <br />EH230038 (revised 0811111) <br />2 <br />