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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 START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A " C �L(Q 3 , <br /> �r_� � <br /> S-d <br /> D Facility Name L I< ��L (IC. Phone# <br /> L Address c prnm <br /> y52 <br /> I Cross Street <br /> Y Owner/Operator Phone# <br /> C Contractor Name Phone# <br /> 0 <br /> N Contractor Address CA Lic# <br /> T Class <br /> AInsurer C 4 Work Comp# <br /> C ICC Technician's Name <br /> T Expiration Date <br /> oICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1n,etc.) Tank Size Chemicals Stored Currently <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved p roved With conditions ❑ Disapproved <br /> L (Se A a me t Wi Conditions) <br /> A -(�— �2— <br /> N Plan Reviewers Name Date J, <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 FORWHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> .......... . <br /> Applicant's Signature Title T Date ZU l <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 Uf[E�CI_" 'jK5/ c `tm.T�ITLtE � <br /> r��✓� /� PHONE# L�J"1 �lSd'�ml <br /> LZ <br /> ADDRESS E6 �i �� OM 10 KiNL 5mff T n I,cn qS k f <br /> SIGNATURE �� DATE GC_ 1 ( 2(1\2 <br /> EH230038(revised 08/1/11) <br /> 2 <br />