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I:NVIRONMENTAL HEALTH DEPARTMENT <br />SAN A iCOUNTY <br />►r L, astM.ain street, <br />California95202 <br />Stockton, <br />Telephone: (209) <br />i(209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING EAI PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT gVDC RE <br />PAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />EPA Site # <br />Facility Name <br />Address__L_;)L 2 - <br />Cross Street <br />Owner/Operator - <br />Contractor Name ~ <br />Contractor Address <br />Insurer �^p <br />ICC Technlclan's Name <br />BCC Installer s Name <br />Tank System work area <br />ti.tr• 87 pipino tamp, 01 Ioak riatamr, CC 112, etc.) <br />Project Contact & Telephone a1 <br />I2i147vZSa_��J <br />d <br />r" ,i!lfllr�' q Phone # <br />CA Lic #��� Class C� <br />�a Work Comp # • , / u' <br />Expiration Date <br />Expiration Date <br />Tank Size Chemical& Stored Currently Installed <br />P FI Approvedpproved with conditions D Disapproved <br />L _{ )QoalchmentWth Conditions) <br />A �_`1-It <br />N Plan Reviewers Name Date <br />AND <br />ULATIONS OF <br />QAQAPPLICANT C UNTY, ENV ENVIRONMENTAL HEALTH DEPRK IN ARTMENT OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, HE FOLLOWINGEGI 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 <br />ISS THE FOLLOWING: *1 CERTIFY <br />TTO RKEWS COMPENSATION LAWS OF CALIFORNIA." HATTIIN THE PERFORMANCE F THE WORK FOR WHICH THIS PERMIT <br />IS SISUED.I SHALL EMPLOY PERSONS SUBJECT To FWoRKER'S COMP NSATION LAWS <br />OF CALIFORNIA." in �p ;j j /� <br />f Y1" l/ ! L'�A11...®. <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 />DATE <br />SIGNATURE <br />EH230038 (revised 02f20/09) <br />