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k <br />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\p UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />UAEPA Site # Project Contact & Telephone # <br />Facility Name Phone # <br />ll Address ,. <br />Cross Street <br />Owner/Operator `rA�k Phone # <br />c Contractor Name s p , ` r <br />Q k7j;�V Phone # "7 <br />N Contractor Address / <br />T CA Lic # ClassW-10 <br />R <br />nsures <br />A FlWork Comp t,tiQQA0MQG G' <br />�, L�� <br />T [ICC:Technician's Name Expiration Date <br />RICC Installer's Name <br />Expiration Date <br />Tank system work area Tank Size Chemicals Stored Currently Date UST <br />em <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed <br />T <br />A <br />N <br />K <br />PApproved ❑ Approved with conditions ❑ Disapproved <br />L <br />A . See A achment With Conditions) <br />N Plan Reviewers Name <br />APPLICANT MUST PERFORM ALL WqK 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: "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 <br />TO -WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S 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 WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Applicant's Signatu_ �TiUe YF � <br />- <br />�Pf��AffiEDate � <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 designafted below is different than the permit. applicant, e.g- property owner, the party must_ acknowledge this <br />responsibility for tth�hee7 billing by signature <br />and date below. �n1 y� <br />NAMEFlIV l!L llQf�(���TITLEA�yl�Tln�- PHONE <br />ADDRESS <br />SIGNATURE_ ��C> <br />• —DATE_ <br />EH230038 (revised 02/20/09) <br />1 <br />