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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 PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# , L :' <br /> Ci Phone# �I <br /> Facility Nam <br /> L <br /> AddressP-tLo0. � <br /> Cross Street <br /> T Phone#Z0 0755>­1Y Owner/Operator ` �X� <br /> C Contractor Name �Y(Lt1 �_ Phone# ct <y <br /> O c CA Li # {( -1 <br /> N t � Class� C.fc! D�[U #� tk'i L <br /> Address loo <br /> O <br /> T N <br /> Contractor � <br /> R Insurer Work Comp# C44• L��2- r�O <br /> Acl <br /> C <br /> T IC hnician's Name Expiration Date <br /> C Tec <br /> 'o Expiration Date <br /> R ICC Installers Name <br /> ' Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e.87 piping sump,91 leak detector,UDC 12,etc.) <br /> T <br /> iA <br /> N <br /> K <br /> P ❑ Approved �pproved with conditions ❑ Disapproved <br /> L (Se Attachment With Conditions) <br /> A <br /> Date <br /> N y� `T-� E-2 <br /> Plan Reviewers Nam <br /> APPLICANT MUST PERFORM ALL ORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRON L HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE O WORKER'S COMPO L NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> F ATIONOAWS OF CALIFORNIA."FOR WHICH THIS CONT AC OERMIT IS UR'S HIRINGLOR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFO ANCE O THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Title <br /> Date v <br /> Applicant's Signature <br /> BILLING INFORMATION: <br /> Indicate the responsib a to billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below ' 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 <br /> TITLE PHONE# <br /> ADDRESS <br /> DATE <br /> SIGNATURE <br /> EH230038(revised 02/20109) <br /> 1 <br />