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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JO►AQUIN 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 />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 <br />TO 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 SUBJECT 70 WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." kh _ „ / / I — _ ! , , <br />BILLING INFORMATIOW. <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 responsibility for the billing by signature and date below. {�{� ^� { <br />p4A TITLE_ { OYPHONE#P.(© <br />A <br />S <br />EH23003a (revised 07122110) <br />F, <br />THIS PERMIT EXPIRES iso DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />REPAIRIRETROFIT O UDC REPAIRIRETROFIT rCOLD STARTIEVR UPGRADE <br />O TANK RETROFIT ❑ PIPING <br />EPA Site # <br />Project Contact & Telephone <br />F <br />A <br />C <br />Facility Name <br />Ph e# —5 •— j <br />I <br />L <br />Address <br />� Y' <br />Cross Street <br />Phone # p r` <br />Y <br />QwnerlOperator <br />Contractor Name <br />r� <br /># O — <br />r <br />CPhone <br />D <br />N <br />Contractor AddressCA <br />Lic q y 13 I� Class — <br />-C <br />T <br />R <br />Work Camp # <br />A <br />C <br />Insurer <br />j <br />Expiration Date 7 �� [ j <br />T <br />ICC Technician's Name l <br />— <br />0 <br />ICC Installer's Name �� <br />Expiration Date <br />LQt.��`S <br />�,� <br />Tank system work area <br />Date UST <br />Tank Size Chemicals Stored Currently Installed <br />(i.e. 97 piping sump, 91 leak detector, UDC 112., etc.) <br />- <br />T <br />A <br />N <br />K <br />L] Approved <br />, pproved with conditions Ll Disapproved <br />P <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <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 <br />TO 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 SUBJECT 70 WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." kh _ „ / / I — _ ! , , <br />BILLING INFORMATIOW. <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 responsibility for the billing by signature and date below. {�{� ^� { <br />p4A TITLE_ { OYPHONE#P.(© <br />A <br />S <br />EH23003a (revised 07122110) <br />F, <br />