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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fag: (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 />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone #hkl I_ <br />C <br />Facility Name <br />Phone ct a <br />IAddress <br />—LEF\ — <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator ` <br />Phone # <br />C <br />0 <br />Contractor Name TE <br />Phone # 269 I- <br />Contractor Address Z�. e <br />CA Lic # <br />N <br />T <br />(� � Class _ t <br />R <br />A <br />Work Comp#� <br />Insurer LfLiup <br />TICC <br />T <br />Technician's Name <br />Expiration Date <br />R <br />ICC Installers Name <br />' <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 12, 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 />(See A ment With Conditions) <br />A <br />N <br />Plan Reviewers Name �� - Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORD\ TH 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 TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />i <br />Applicant's Signature Title �}r U�Q�)f'�'c�C f�}C�l �� pate <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 responsibility for the billing by signature and date below. li <br />NAME N t 1 t Lj,)\L' Ac-� TITLEt(i)rl, l )(1 PHONE # 2CTJ. -nKc 57 <br />ADDRESS <br />SIGNATURE DATE -9 <br />EH230038 (revised 07/22/10) <br />