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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 />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />c <br />O <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />P <br />L <br />A <br />N <br />THIS PERMIT EXPIRES 1130 DAYS FROM THE APPROVAL DATE. INDICATE PERMrryyYPE BELOW: <br />TANK RETROFIT PIPING REPAIR/REfROFrf❑UDC REPAIRIRETROFIT EICOLD START/EVR UPGRADE <br />EPA Site # Project Contact & Telephone # 1 _ <br />Facility Name Q ` Phone # <br />Address �3 l� F P -,-)t <br />Cross Strut <br />Owner/Operator <br />Contractor Name <br />Contractor Address <br />Insurer rth. ( mu.I. <br />ICC Technician's Certification Number <br />ICC Installers Certification Number <br />Plan Reviewers <br />Tank ID # <br />DApproved <br />Phone # �� y — 5 `7 <br />Phone # _ <br />CA Lic # (�� Class <br />Work Comp #W <br />Expiration Date <br />Expiration Date <br />Tank SizeI Chemicals Stored <br />Currently/Previously <br />'LVApproved With conditions <br />j41tachment With Conditions) <br />Date UST Installed <br />❑Disapproved <br />APPLICANT MUST PERFORM AkC'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 FOLLOWryNG 'I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS IN BECOME SUBJECT TO <br />WORKERS COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS 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 WORKERS COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Applicants Signature Title f ,"U fc nk 1R 1 Date �C LQ 1J.J ll <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. L <br />NAME�tm �?�"� ) TITLE _ C \���PHONE #_I�f <br />ADDRESS Z_ l) ( ). ) k U -I(l) 1 I 1 J)hl\[f jLl <br />LlI-�n�T <br />SIGNATURE 1 I <br />EH230038 (revised 12/31/07) <br />I <br />0 <br />