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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 EPA Site# Project Contact&Telephone#X9Ili tr <br /> A <br /> O Facility NameCj�c AfiW Phone# _ <br /> i Address <br /> TCross Street <br /> Y Owner/Operator Phone# <br /> o Contractor Name v Phone# _ <br /> T Contractor Address CA Lic# Class - <br /> R Insurer , .� <br /> A Work Comp# O7Q� <br /> T ' <br /> echnicians Name <br /> T ICC TExpiration-Date <br /> o ICC Installer's Name <br /> R Expiration Date - `y <br /> Tank system work area Date UST ` <br /> (i.e.87 piping sump,91 leek detector,UDC trz.etc.) Tank Size Chemicals Stored Currently Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ ApprovedApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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: "1 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 /> LFY <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 Signaturej�h TiUe� � YCJ <br /> Date <br /> BILLINt` uvruKMATION: <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. �`m <br /> NAMEEtR-) it 0—CW TfTLE�I�t I r L� PHONE�LL�L J I 11� � <br /> ADDRESS-2�� r`kCILJ �� �� `TDGU <br /> SIGNATURE DATE <br /> EH230038(revised 02/20/09) <br /> 1 <br />