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1�," r,+♦�"1+'Y1l++Y�r! 1t !! ►��+i'/! 1 • AI / ,. I! f+ �:;!"t`R <br /> to <br /> I , <br /> C <br /> , ., <br /> I <br /> 1 ENviR* ONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East MainStreet, Stockton, California 95202 <br /> t Telephone: (209)468-3420 Flax: (209)468-3433 <br /> APPLICATION FOR UNDERGRdUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> El TANK RETROFIT D PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone.#._ _ __._ 7. <br /> c Facility Name Phone# <br /> I I <br /> L .Address r' r , <br /> 'i Cr;l _ , <br /> TCross Street <br /> Y OwneNODeratnr Phone# _ <br /> Contractor Name <br /> 0 Phone# <br /> N Contractor Address <br /> T CA Lic# ��� ClassA V A-iA <br /> Ainsurer <br /> s Work Comp# <br /> c Ug w-( <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 Current) Date UST <br /> 0.e.87 piping sump,91 leak detector,UDC 1/2,etc.) y Installed <br /> T <br /> A <br /> N <br /> K <br /> . .. <br /> L ❑ Approved pproved with conditions El Disapproved <br /> A (S a Aft h t With Conditions) <br /> N Plan Reviewers Name <br /> 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,i SHALL NOT EMPLOY ANY PERSON.IN SU.GH A.MANNER.AS.TO BECOME SUBJECT-TO <br /> WORKER'S-COMPENSATION-CAWS 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 IS$UEO,I SHALL EMPLOY PERSONS SUBJECT T.O WORKER:S_COMPENSATION.LAWS,,, <br /> OF CALIFORNIA _-..._...,..,.. <br /> Applicant's Signature Title <br /> Date <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 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 E.�1�TE•fll(°(1�'1TR1�C.[('(Z'S1�'C1CI�lYI1�U�}Lrlti (� _ <br /> PHONE#_2� �1-62b] <br /> _. ADDRESS.__.____ C tI�)1('1l\`)A'l�� 1C►�i � � ������ <br /> SIGNATURE DATE_ <br /> EH230038(revised 08/1/11) <br />