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0 • <br /> 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 V UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � <br /> Facility Name j Phone# q. y5s . 10 <br /> Address <br /> Cross Street <br /> T <br /> Y Owner/Operator Y-JOID NX Phone# 70 6 D3 <br /> 0 <br /> Contractor Name ��Q (� Phone# 9 � �v U <br /> T Contractor Address IV- ��rSA j� CA Lic# j� Class(7J �b, D <br /> R <br /> A Insurer Work Comp# <br /> C <br /> T ICC Technician's Name �f"1�Q� Expiration Date _V 1 1 <br /> RICC Installer's Name b) o1_S Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (re.87 piping sump,91 leak detector,UDC 112,etc.) Installed <br /> T S�. u <br /> A <br /> N <br /> K <br /> P Approved 1 !Approved with conditions Disapproved <br /> A (See cVment With Conditions) <br /> i/1 1 q ) <br /> N Plan Reviewers Name 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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> ,,(J Kn <br /> Applicant's Signature Lie^'�f/'-"-` Title �(QC �/ ` Date f <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 <br /> SIGNATURE DATE <br /> EH230038(revised 08/1/11) <br /> 2 <br />