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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 F <br /> O Facility Name - Phone# _ 1 <br /> I Address <br /> L <br /> TCross Street <br /> Y Owner/Operator - Phone# <br /> Q <br /> o Contractor Name <br /> Phone <br /> N mc.Contractor Addess r <br /> T L1IA]8PMQN-qf�: . CA Lic# Class <br /> R Insurer _ _ <br /> A <br /> Work Comp A 90 2j_ 1 - .<<j <br /> T ' <br /> ICC Technicians Name Expiration Date <br /> RICC installer's Name <br /> Expiration Date <br /> Tank system work area - <br /> (I.e.87PlpingwM,91 leak detect«,uDC in,aw.) Tank Size Chemicals Stored Currently Date USTInstalled <br /> T <br /> A <br /> N <br /> _K ._. ....__ _.. <br /> P ElApproved pproved with conditions ElDisapproved <br /> -A - - -- Se chm t WithConditions) <br /> N Plan Reviewers Nam 9 J / <br /> Date <br /> APPLICANT MUST PER ALL'WORK ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN.COU NTY, ENVIRONMENTAL LTH 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 EMPLOY ANYPERSON 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 SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' '- <br /> AppilmrfsSlgnalure Thle . .. _ _ .. <br /> Date <br /> BILLING INFORMATION: <br /> Indicate the responsibleparty 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 forthe billing by signature and date below. <br /> NAME EI I fE.m P(�(1TRFl 7i S r PCI �(m n�TL1etlf �Cll } 1 <br /> of ` 1,� It((L_PHONE# 2CA OI A� 1 <br /> ADDRESS 7< 1�/ Ll `�'}tl G.IyE 5M=4 <br /> SIGNATURE_ `( \tYY1 (.% )61Jr) DATE <br /> EH230038(revised 08/1/11) <br />