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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 /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMITYYPE BELOW: <br /> ❑TANK RETROFIT PIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE .. <br /> A F EPA Site# Project Contact&Telephone# L _ <br /> G Facility Name Q q Aone# <br /> L Address �"� , r <br /> ICross Street <br /> T <br /> Y Owner/Operator AN,ff Phone# <br /> C Contractor Name 11-1 Phone# <br /> o _ <br /> TContractor Address CA Lic# �� <br /> R "Dat <br /> _ <br /> CInsurer aP Work Co _Q <br /> T ICC Technician's Certification Number EVxpiratio <br /> RICC Installer's Certification Number <br /> Expiration <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved Approved with conditions ❑Disapproved <br /> L --, See Attachment With Conditions) <br /> A i �4e <br /> NPlan Reviewers Name i—7 —___` Date <br /> APPLICANT MUST PERFORM ALL 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 FOLLOWING: "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 TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 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 /> Applicants Signature ` Title Date <br /> BILLING IN RRATION: <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 <br /> �by\ signature and date below. L ,, 1 / <br /> NAME \C�(1 V. �l\V TITLE Cif t'�t''� 1 l��J PHONE# � l4 <br /> ADDRESS <br /> SIGNATURE 4AWJ &\ <br /> EH230038(revised 12/31/07) <br /> 1 <br />