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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 TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ACOLD START�/EVR UPGRADE <br /> / <br /> F EPA Site# Project Contact&Telephone# -& - <br /> A Phone# 21)6)- <br /> C <br /> 21)6-C Facility Name <br /> L <br /> Address Q / <br /> TCross Street <br /> Y Owner/Operator Phone# .22 <br /> cContractor Name G(, f'`J <br /> ° <br /> N Contractor Address S CA Lic# <br /> T <br /> R Insurer Work Comp# <br /> A <br /> C ICC Technician's Name Expiration Date <br /> T u 20dD <br /> R ICC Installer's Name ®� Expiration Date <br /> Date UST <br /> Tank system work ea Tank Size Chemicals Stored Currently Installed <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) <br /> T <br /> A <br /> N <br /> K <br /> P <br /> ❑ Approved ❑Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Plan Reviewers Name Date — <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: "1 CERTIFY THAT IN <br /> THE PERFORMANCE TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.-ICH THIS CONTRACTOERMIT IS R'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A IES THE FONNER AS LLOWING:"'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 <br /> Title Date <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional END 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 <br /> /for the billing by signature and date below. <br /> TITLE C PHONE# <br /> NAME G <br /> ADDRESS /"D �Ok `SS�l1 S "'" C� �� "/ ✓ ✓ 'w /� <br /> DATE <br /> SIGNATURE <br /> EH230038(revised 02/20/09) <br /> 1 <br />