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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 <br />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 />EPA Site # <br />Project Contact & Telephone # C <br />� <br />Facility Name 1 <br />Phone <br />L <br />Address <br />Cross Street <br />T <br />Y <br />�` <br />Owner/Operator 1 N 'u ( <br />Phone# <br />C <br />Contractor NamePhone <br /># <br />0 <br />N <br />T <br />Contractor Address <br />CA Lic # ClassAbclh <br />AInsurer <br />>`tob <br />Work Comp # C) <br />T <br />ICC Technician's Name <br />Expiration Date <br />RICC <br />Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Ipproved with conditions ❑ Disapproved <br />See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Nam /� �G Dated �1 <br />APPLICANT MUST PERFORM ALL VVORK 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 CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 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 Titleftwanb�iDate <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 EIUE.mMnTR+aczc , rnc_)jITL ' <br />- I '\PHONE # Ll� lS/ l �_ <br />ADDRESS WV_,(jj (y�� �) <br />(O�-0QK1_TW rrCXA 959dr <br />SIGNATURE ` ` Nth— ( k�1 k) DATE__' X11 t3 <br />EH230038 (revised 08/1/11) <br />2 <br />I11"A <br />