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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUM 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 /> A EPA Site# P ojeat Contact&Telephone.# 1; 'S <br /> C Facility Name (,� f ��� Phone# 4 <br /> I Address 11,15 r <br /> T <br /> Cross Street <br /> Y Owner/Operator lam` Phone <br /> cContractorName <br /> D Phone# _ <br /> N : Contractor Address <br /> T y�� y� ((_j��m �('�, A Lic# Class <br /> A Insurer el Y f)LL ka / <br /> -�Q L , Work Comp t <br /> TICC Technician's Name <br /> Q Q)UIDD jiv Expiration Date <br /> R ICC Installer's Name Expiration Date <br /> Tank system Work area Stored Currently Chemicals S <br /> Tank Size ChemDate:UST <br /> (i.e.87 piping sump.91 leak detector,uoc M.aic.) - y Installed. -- <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ;'Approved with conditions El 'Disapproved' <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> Date O <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 COMP SATION LAWS OF.CALIFORNIA." CONTRACTOR'S HIRING.OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY <br /> THAT IN THE PERjRr4CE OF THE WORK FOR WHICH THIS-PERMITIS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OFCALIFORNIA.'Applicant's Signatul.(.'�Tjye 01 iF4V 1 i �iU 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.Tthe <br /> r billing <br /> �blyrsignature <br /> �and date below. <br /> NAMEE, I}eJ LlL Ciel Illar JQ Nei--TITLE ��,1�;1�1 rl[I�lt� PHONE 1 <br /> ADDRESS J(��l I� � =el-11L11 x– t e o 'tSLb,) — <br /> SIGNATURE_ <br /> - 'DATE <br /> EH230038(revised 02/20/09) <br /> 1- <br />