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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 STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A - -a <br /> C Facility Name nje Phone# <br /> L <br /> Address <br /> TCross Street <br /> Y Owner/Operator cPhone# <br /> C Contractor Name __ _ Phone# <br /> — --0—-— <br /> T Contractor Address a CA Lic# WgOO-71j2Class 13,C_/o Z <br /> R Insurer 'J Work Comp# <br /> A Xplorcir <br /> TICC Technic n's Name Expiration Date <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (.e.87 piping sump,91 leak detector,UDC 12,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved roved with conditions ❑ Disapproved <br /> L (Se) ch ent With Conditions) <br /> A <br /> N <br /> Plan Reviewers Nam Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCOR 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 COMP SATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFO NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA."Applicants Signature jhl�u Title Date / 2 <br /> BILLING INF MATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below is different than the permit applicant, e.g. property owner,the party must acknowledge <br /> this re711^�16C <br /> nsibility for the billing by signature and date below. <br /> NAME e i/ TITLE (7�1LL Nil rI U PHONE# �D <br /> ADDRESS 1 �7 Or- �rl�l 11 <br /> SIGNATURE DATE 7 <br /> EH230038(revised 07/22/10) <br /> 2 <br />