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r• <br /> 4ENVIRONMENTAL 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# �Q4 A.DOMS (q/ 6SS/Oj <br /> A <br /> G Facility Name J k6- Phone# c-()3g 1 <br /> � Address 16S-00 S. NAYZL.4(,J )Z,[) LA")-HfLZV C4 qYZIcD <br /> Cross Street <br /> T 110vfS 4v,v' <br /> Y Owner/Operator A c Phone# -Lo - 1103- <br /> 0 <br /> 1103-- <br /> o Contractor Name M e ! /(. YS 0 Vg L)Cp 0,0 Phone# g/6 <br /> T Contractor Address , 0 1-3oy /fig CA Lic#/�( y� Class C <br /> A Insurer s Work Comp# .ZOb-4 <br /> T ICC Technician's Name 3AB `0 9-.` i®VZ- Expiration Date 9/2�� T� <br /> o ICC Installer's Name <br /> R ZK- W I(,K t Expiration Date /�l?o ®!D <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <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 AGENTS 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 <br /> To 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." �t <br /> Applicant's Signature Title /®4,4 Date v ®® <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 02/20/09) <br /> 1 <br />