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N:--� I �� .-.r i r 1 , r 1 4+ Y r sf f r�i!f !t.1•,.l tt - Y i l i 1 1 . 4 1 r. ry f 1 1 r .'� <br /> } o i� " � ,/ <br /> fr y it <br /> 1 f , f r 1 r• ! � <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> t <br /> 4 SAN JOAQUIN COUNTY <br /> 600 East Mafn Street, Stockton, California 95202 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> I <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> j THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> I ❑TANK RETROFIT D PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT D COLD START/EVR UPGRADE <br /> i <br /> I F EPA Site# Project Contact&Telephone#: <br /> _ <br /> A - <br /> I C FacilityName Phone <br /> Address qjt, 5, - <br /> q . , <br /> T Cross Street <br /> Y Owner/Operator Phone# <br /> cContractor Name <br /> o Phone# <br /> N Contractor Address <br /> T CA Lic# <br /> R Class <br /> Insurer <br /> A ` Work Comp# _rte <br /> T ICC Technician's Name `b <br /> Expiration Date <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detec(or,UDC 1f2,etc.) - <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions <br /> El Disapproved <br /> A (See chment With Conditions) <br /> N Plan Reviewers Name 6 �� <br /> Date 4 <br /> - ------- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS,AND RULES AND REGULATIONSO F 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,!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 /> halApplicant's Signature—&= fP�11�((� 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 /> _ <br /> _ <br /> 1 _ <br /> NAME E I ITE.ID(°t1f1�R1� n �/ _1 WITITLE �lf� _PHONE# 2 A 111(o 1p,J,A <br /> ADDRESSc <br /> SIGNATURE <br /> DATE_ - <br /> EH230038(revised 08/1/11) <br />