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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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ZUDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility Name <br />Phone # obi, <br />I <br />L <br />Address es ��. �Dn qK <br />ICross <br />T <br />Street <br />Y <br />Owner/Operator <br />Phone # cas- 7 - 05tpb <br />C <br />0 <br />Contractor Name ' (` <br />Phone # 1(0 - 3'7I- 8C <br />N <br />T <br />Contractor Address �, �,( C`'lj3 k„�� ( <br />CA Lic # I, Class <br />A <br />Insurer <br />Work Comp # IOU OI S00 <br />0ICC <br />T <br />Technician's Certification Number 5 /► _"S' <br />Expiration Date �-� �- O <br />0 <br />R <br />ICC Installer's Certification Number <br />Expiration Date I - -Q <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />❑Approved pproved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />(// / l <br />Plan Reviewers Name Date l 2 — 1 V:D <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 AGENT'S 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 TO <br />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 />V�II <br />Applicants Signature Title Date <br />BILLING INFORMATION: -j <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. <br />NAME TITLE PHONE #, <br />ADDRESS <br />SIGNA <br />EH230038 (revised 8/3/07) <br />1 <br />