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02/26/2009 08:48 FAX [a 001 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JO.AQUIN COUNTY <br /> 600 East Main Street,Stockton, California 95202 <br /> Telephone: (209)468-3420 Fax: (209) 4683433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TH(S pEr,mIT EXPIRCS 180 DAYS FROM THE APPROVAL.DATE. INDICATE PERU ITTYPE t3 LOW. <br /> ❑ TANK RETROFIT ❑ PIPING RI=PAIR/RETROPIT ❑ UDC REPAIRIRETROFIT FCOLD suR-r4ER UPGRAD <br /> F EPA Site# Project Contact&Telephone# 7-oq7 —&r <br /> A Facility Nam �' ,� C Phone <br /> C <br /> L Address '� � � � � r� ► <br /> Tcross street <br /> P r1r�1t1 t�.l Y 1 _ <br /> Y Own IO eralor - — Phone or. r <br /> o Contractor Nam G Phone# <br /> T Contractor Ad _coo o> � _ CA tic ped�D5' Class �l A <br /> A Insurer • �� � ! Work Comp# 6� i <br /> C ICC Technician's Name Expiration Date <br /> T <br /> o <br /> R ICC InSt�3fler'S Name Expiration Date <br /> Tenk system work area Tank Size Chemicals Stored Currently Date UST <br /> 0,e,A7 porlo sum,e t IeA dnrnCier,UDC uz etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> p ❑ Approved -Approved with conditions ❑ Disapproved <br /> L /(See Attachment With Conditional <br /> A <br /> N Plan Reviewers Name Date v <br /> APPLICANT MUST PERFORM ALL RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOACU(N COUNTY,EN✓IRONUEN AL Ht A).TH DEPARTMENT,OWN CR OR LICEN$ED ADENT'S SIGNATURE CERTIFIES THE FOLLDWING: 'I CERTIFY THAT IN <br /> THIS PCRFORMANCE OF TFIE W RW <br /> S <br /> K FOR HICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 6EDOME SUBJECT <br /> 70 WORKERP AIF LgrRACTCR'$HIRING OR SUBCONTRACTINO SIGNATURE CERTIFIES THE FOLLOWINp; "I CERTIFY <br /> THAT IN <br /> T. <br /> pErtF RMAN E O• FIE WORK FOR WI-ACH Z PERMfT IS JS3UEb,I SHALL EMPLOY PERSONS SUBJEC7 TO WORKER'S COMPENSATION LAWS <br /> OF CALFORNIA'// <br /> Applkaife51yn1lpre TIUe Dille Z&r4eoa <br /> BILLING INF RMATION; 71 <br /> Indicate the responsible party to be billed for additional EHD staff time expanded 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 /> MSponsibility for the bllling by signature and date below, <br /> NApRE.15 <br /> i�cr1�S F � 7fTLE�1� D� PHONE fu / <br /> ADDRESS A-L_ • , T_)AJ r <br /> 5 NATURE DATE9 <br /> H230038(revised 02J20/09) <br /> 7 <br />