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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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />TANK RETROFIT PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name - V ` <br />Phone # <br />I <br />L <br />Address l "l q�J- <br />TCross <br />Street <br />Y <br />Owner/Operator - v ( <br />l one # <br />oContractor <br />Name Phone # <br />TContractor <br />Address , 0 . Da5 <br />CA Lic # a Class <br />R <br />A <br />Insurer res. <br />Work Comp # r11,3- Q�v <br />C <br />T <br />ICC Technician's Certification Number <br />Expiration Date <br />D <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />/ <br />e <br />j� i <br />A <br />N <br />K <br />P <br />Approved t/Approved with conditions Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />r� <br />f/� Date <br />Plan Reviewers Name /j'4AAj In 64q -Z— (JM -(if 7 �3 /P K <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 TO <br />WORKER'S COMPENSATION LAWS OF CALIFO NIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMA E OF THE WORK I, R WHICH THIS PERMIT IS I SUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />r <br />Applicants Signature Title Date <br />- I U 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 appli , e.g. property owner, the party must acknowledge this <br />responsibility f r the billing by signatur, and date belo . <br />NAME (�1 F� TITLE PHONE # (J Q l <br />SIGNATU <br />EH230038 (revised 8/3/07) <br />