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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 �fjj 6M cYi Z 7 -t <br /> � <br /> Facility Name >! � Phone# I 1�t I tc <br /> I Address <br /> L <br /> Cross Street <br /> T Phone# _ <br /> Y Owner/Operator \\ 6L W Y1C <br /> CContractor Name Phone# <j j l< aZ�7 77 X <br /> o z� <br /> N - CA Lic# r 1 �41 Class�jC l C)qC' if 2 <br /> T Contractor Address ) .� (�� <br /> R Insurer Work Comp# Lr �} C <br /> A ru nl <br /> T ICC Technician's Name �� m 1 Expiration Date c <br /> o ICC Installer's Name �; Expiration Date <br /> R yrn P,d' <br /> Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) <br /> T <br /> A <br /> N <br /> K <br /> P <br /> ❑ Approved L�'Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> Atl 13 TS� <br /> N Plan Reviewers Name YM ' �� 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 FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH AAS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATIONORK LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERT FRIES THE FOLLOWIG: "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 /> Date <br /> Applicant's Signature <br /> Title <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 <br /> TITLE PHONE# <br /> ADDRESS <br /> DATE <br /> SIGNATURE <br /> EH230038(revised 02/20/09) <br /> 1 <br />