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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 RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # �� v l'� — 0ob <br />C <br />Facility Name Thc)mtunUrcleK <br />Phone # 2vq 1 <br />1 <br />L <br />Address gtoV <br />TCross <br />Street ' <br />Y <br />Owner/Operator <br />Phone # <br />C <br />0 <br />Contractor NameAF-CPhone <br /># <br />NContractor <br />T <br />Address T. 0 , 015 <br />CA Lic #,Qj Class <br />RInsurer <br />A <br />t fund <br />Work Comp # <br />C <br />Ttiger <br />ICC Technician's Name1 <br />Expiration Date a <br />oZ I <br />RICC <br />Installer's Name �15� <br />Expiration Date . 1 <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Current) y <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(fee Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date S— <br />S- iJ <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 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 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 TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Applicant's Signature Title 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 the billing by signature and date below. �/� /�/� <br />NAME�1 TITLE I/�nt PHONE # vO0 <br />ADDR <br />SIGNA <br />EH23C <br />