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ENVIROIIENTAL HEALTH DEIARTMENT <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 ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility Name I ` Phone# -4 <br /> IAddress tid TE- q 5 '0 <br /> L <br /> TCross Street <br /> Y Owner/Operator 601a obilla) Phone <br /> C Contractor Name Phone# <br /> N <br /> T Contractor Address 2= 11WAIM CA Lic# Class <br /> R Insurer A �1(�• Work comp# LbCVJ316"C)\ <br /> C ICC Technician's Name <br /> T Expiration Date <br /> R ICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Date UST <br /> (i.e.87piping sump,91leak detector,UDC 1/Zetc.) Tank Size Chemicals Stored Currently <br /> Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved PRApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A , pp <br /> N Plan Reviewers Name Date 7— <br /> APPLICANT <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 LA 1NS 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 WORKERS_COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signatu.-4 Title Date <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 U`1E. 60MR T)KS/ �1m WIC <br /> TITL <br /> �j�✓��✓)_] [ T) {l�(C� PHONE#�1 � <br /> ADDRESS 2-5� (A)VI M Ip r,ht, 1316 KM rM 15 (t <br /> SIGNATURE `T �� �� —DATE_ �2 <br /> EH230038(revised 08/l/11) <br /> 2 <br />