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_ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, 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 INEIPING REPAIR/RETROFIT ❑UDC: RFPAIR/RFTRnFIT <br />F <br />A <br />EPA Site # <br />Project Contact & Telephone # <br />C <br />Facility Name �. �' <br />Phone # - <br />\ <br />L <br />Address autom r <br />1 <br />T <br />Cross Street <br />Y <br />Owner/Operator Phone# <br />C <br />Contractor Name 1 <br />Phone # XCA AW <br />T <br />Contractor Address �M <br />CA Lic # b(OM6 Class Aft_1 t <br />R <br />A <br />Insurer <br />Work Comp # L5 1 -® <br />T <br />ICC Technicians Certification Number <br />' <br />Expiration xpiration Date <br />RICC <br />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 />A <br />N <br />K <br />P <br />f <br />❑Approved proved with conditions []Disapproved <br />1- <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name _ Date- Z 2—� <br />APPLICANT MUST PERFORM! ALL ORK 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: "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 TO ' <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br />OF CALIFORNIA." EERFORMANCE OF -THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY FERSONS SUBJECTTOWORKER'S COMPENSATION LAWS <br />_Title l �����n�� `UV 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 IM�1 ��� , TITLE �Q J PHONE # 7,6 jCd <br />ADDRrSS 11�j1L)b\jk5JSl=L�_l�� • C), -j <br />SIGNATURE of 1 �Y/1153� <br />EH230038 (revised 8/8/06) <br />