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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 UNDERGROOYND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT gPIPING REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT -I <br /> F EPA Site# Project Contact&Telephone# (p,t (.Zed <br /> Facility Name Phone#IAddress , <br /> Cross Street I <br /> Y Owner/Operator t Phone# <br /> C Contractor Name rc, Phone#���, U <br /> N Contractor Address 11L stn L CA Lic# 2,2 1�� Claassqb <br /> T G <br /> A Insurer L ( Work Comp# ZZ t- I� bub, <br /> cICC Technician's Certification Number Expiration Date <br /> T <br /> R ICC Installer's Certification Number �(t�jL{L Expiration Date <br /> Chemicals Stored Date UST Installed <br /> Tank ID# Tank Size Currently/Previously <br /> A 2 1 <br /> K �JO01 k <br /> P ElApproved Approved with conditions ❑Disapproved <br /> L e A achment With Conditions) <br /> A1N Plan Reviewers Name Date--2]— <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,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PIRIFOR NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." f�(L <br /> Applicants Signature Title V w Date U(, <br /> A�n <br /> BILLINt I ORMATION: <br /> Indicate the responsible party to be bill d for additional END staff time expended beyond permit payment coverage per tank. If <br /> the parry designated below is differe th n the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing bysignaturean date below. <br /> NAME TITL PHONE# CIA <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/3/07) <br /> 1 <br />