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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 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 REPAIRIRETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Ntn " i <br /> A _ <br /> C Facility Name VPhone# _ <br /> DIE <br /> L Address <br /> TCross Street <br /> Y Owner/Operator a Phone#209 1 W81 3 <br /> C Contractor Name Phone# <br /> ' I Contra Address <br /> T c( CA Li # ClassAh <br /> R Insurer, <br /> A T Work Comp h <br /> c ICC Technician's Name <br /> T Expiration Date <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size ChemicalStd CurrentlyDate UST <br /> (i.e..87 piping sump,91 leak detector,UDC 1ns ore <br /> ,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (Se hment With Conditions) f <br /> N Plan Reviewers Name ' Date P� <br /> ._....._..... <br /> _. <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 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." <br /> Applicant's SIgnature Title Date I <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 IX-"CJ- TITLE&h(1V?nb j(r C PHONE# ib I Atd.. <br /> ADDRESS '1'(�1,�•IA 9.iNL 111] Tr N 1 966 <br /> SIGNATURE <br /> �1 1�� DATE f&. /146L <br /> EH230038(revised 08/1/11) <br /> 2 <br />