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ENVIRONMENTAL HEALTH. DEP I ARTMENT <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 # <br />A. . <br />C Facility Name �AYY1 �►,�(`\ t 'CYZO��'�- `a Phone # <br />d Address <br />16 *13 , <br />T <br />Cross Street <br />Y Owner/Operator Phone # <br />C <br />Contractor Name ' Phone # <br />N Contractor Address _ <br />T A Lic # Class <br />R Insurer 'O T <br />10 <br />A Work Comp # <br />0 ICC Technician's Name ' i <br />T Expiration Date <br />Qnstaller's Name <br />R ICC I� � Expiration Date <br />Tank system Work area Date:UST <br />(i.e. 87 piping sump, 91 leak detecW, UDC 1/2. etc.) .Tank Size Chemicals Stored Currently Installed-. <br />T <br />A <br />N <br />K <br />P ❑ Approved Approved with conditions ❑ Disapproved <br />L <br />A (See Attachment 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 />ll 1E PERFORMANCE OF THE. WORK -FOR- WHICH -THIS: PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />"TO-WORKER'SA <br />.ICOMPENSATTON LAWSF.CALIFORNIA." CONTRACTOR'S HIRING.OR SUBCONTRACTING SIGNATURE CER TIFlES THE FOLLOWING: -1 CERTIFY <br />THATIN 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 />Applicant's Signature Title - 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 forthebilling by signature and date below. { � p� ,/ rr��rnrn -6 <br />J��?� <br />TITLE �(T(,�)t 1olt1 rri��f PHONE. ��46 � 6561 <br />ADDRESS—= <br />SIGNATURE DATE <br />EH230038 (revised 02/20/09) <br />1 <br />