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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 RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT;fYPE BELOW: <br /> TANK RETROFIT OPIPING REPAIRIRETROFIT ❑UDC REPAIRIRETROFIT DCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# f'` j _ - <br /> A <br /> C Facility Name Phone <br /> I Address n L i i {` <br /> L <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> cContractor Name _ <br /> O ��� Phone# <br /> NContractor Address <br /> T CA Uc# �� Class <br /> R <br /> Insurer <br /> p( Work Comp#CoQ Lb ZtIg-(OX <br /> T ICC Technician's Certification Number <br /> Expiration Date <br /> R ICC Installer's Certification Number <br /> Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> L DApproved Approved with conditions Disapproved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> 'r>1' Date (nab 11 <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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 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 /> Applicants Signature ` Tide 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 /> NAMES`\�R L "� � TITLE PHONE <br /> ADDRESS t J l 1 n ��t t;1 � �, �� 51Q <br /> SIGNATURE <br /> EH230038(revised 12/31/07) <br /> I <br />