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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone:(209)468-3420 Fax:(209) 3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW_ <br /> UTANK RETROFIT UPIPING REPAMETROFIT LJuDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name Phone# <br /> I Address <br /> L <br /> I <br /> Cross Street <br /> T <br /> Y OwnerlOperator Phone# <br /> C Contractor Na Phone# <br /> O <br /> N Contra Ad ss � , CA Lic# Class419',/6 <br /> T <br /> R Insurer Work Comp# P&® 77 <br /> A <br /> C <br /> T ICC T kzan's Certification Number Expiration Date <br /> O <br /> R ICC installer's Certification Number 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 UAppmved proved with conditions UDisappraved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name <br /> APPUCANT MUST PERFORM ALL.WOW IN ACCORDANCE kSAT 4:SAN JCYk iN COUNTY ORDINANCES,STATE L"4S AND RULES AM REGULATIC11M OF SAN <br /> JOACUN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LX24SED AGENTS SIGNATURE CERTIFIES THE FOLLOVA4G: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WAC FOR WHIG THIS PERMIT IS ISS,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S LAWS OF CAUFORNIA" CONTRACTORS HIRING OR SIGNATURE CERTIFIES THE FOLLY: "I CERTIFY <br /> THAT IN THE PERFORM OF THE WORK FOR WHICH THIS PERMIT IS ISSUIP,I SHALL EMPLOY PERSONS SUJB.ECT TO WORICERYS COMPENSATION LAMS <br /> OF CALIF A. m <br /> APPS Sigrahae Tit@ IDate <br /> BIWNG FORMATION: 61 <br /> Indicate the responsble party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party a permit ignated below is different than the peit applicant, e.g. property owner, the party must acknowledge this <br /> responsr ityfor the billing by signature and date below. <br /> NAMETITLE Ki PHONE# /^ <br /> 14� <br /> ADDRESS z <br /> r I <br /> SIGNATURE <br /> EH230038(revised 8/8!06) <br /> 1 <br />