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ENVIRONMENTAL HEALTH DEPART HDD <br /> SAN JOAQUIN COUNTY FEB 2 6 2010 <br /> 600 East Main Street, Stockton, California 95202 ENVIRONMENT HEALTH <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 PERMIT/SERVICES <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 EPA Site# Project Contact&Telephone# <br /> � Facility Name ,^�^/n �� �j(� Phone#7--ir <br /> Address 3 2 z �� U { Il L ca-Ul�Cl t C cl Z l (� <br /> TCross Street <br /> Y Owner/Operator Phone# <br /> C Contractor Name--( Phone#�) _ (o f-- /'Zc{(o <br /> TContractor Address Q 1 CA Lic# Class <br /> A Insurer&,,-Ie <br /> ,,- l C ( 0/k- Work Comp# <br /> QICC Technicians Name <br /> T ' lt/ 5,25qys6 c(T Expiration Dated 23 <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2.etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P LI Approved 'Approved with conditions Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date----3// <br /> APPLICANT MUST PERFORM Al I WK.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 TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />