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fENVIRONMRTAL HEALTHT T <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# �Nk_ (o Project Contact&Telephone# <br /> A ( <br /> O Facility Name Phone# . 2 r <br /> I Address V <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# -(. <br /> Contractor Name S Phone#o <br /> N Contractor Address , "� <br /> T CA Lic# Class <br /> AInsurer Work Comp# <br /> TICC Technician's Certification Number Expiration Date i ®1 <br /> O <br /> R ICC Installer's Certification Number 'rj25 01 Uj_ Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P ❑Approved VApproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name—Afw4 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 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 FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants 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 for the billing by signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS 1 7- " y <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> 1 <br />