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ENVIRONMENTAL HEALTH. DEPARTMENT <br />SAN IOAQUIN COUNTY <br />_600=Fast-�¢ain=Streeti-Stockt-on C-C-aff-or-on,-95202----------- ----- <br />Telephone: (209) 468-3420 Fax: (209) 468=3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PER <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑. TANK RETROFIT ❑ PIPING REPAIR/RETROFIT'' ❑ UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br />F EPA site # Project Contact & Telephone # <br />A_ Facility. Name Q <br />1. Address <br />T . <br />Cross Street. . <br />Y: Owner/Operator <br />Phone #:.. <br />Contractor -Name <br />o : Phone.# . <br />N <br />T Contractor Address A Lic # Class <br />R <br />A Ipsurer. . Work Comp # <br />0 "17 00 <br />T ICC Technician's Name Expiration Date <br />R ICC Installer's Name _ <br />Expiration Date <br />Tank system work area Tank Size Chemicals Stored CurrentlyDateUST <br />: <br />(Le. 87 � 9=4k 911eM deleclor, UDC 12, e1r.) .. <br />installed. <br />T <br />A <br />N <br />K <br />rN ❑ Approved �J Approved with conditions ❑ Disapproved <br />e chM meat With Conditions) <br />%401Name Date <br />APPLICANT MUST PERFORM ALL WORK 1N ACCORDANCE WITH SAN JOAQUIN..000NTY ORDINANCES, STATE LAWS,.AND RULES AND REGULATIONS OF SAN <br />JOATJUIN COUMl'; ENVIRONMENTAL HEAL DEPART OWNER OR -LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN <br />THEPERFORMANCE OF THE WORK FOR WHICH THIS. PERMIT IS ISSUED.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A_MANNER AS TO BECOME SUBJECT <br />To-woRKE m1comPENSAnoN`LAWS OF.CAl.1FORNIA.• ,CONTRACTOR'S HIRWG.OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br />THATJN THE PERFORMANCE OF THE WORK FOR.WHICH THIS`PERMrr IS ISSUED, J SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF.CALIFORNIA.• <br />Applicant's Signature TWAD <br />i <br />Date. <br />BIWNG 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, I I.6 19 C"OC (Nc1 ITLE1EPk5`I r71V6 PHONE <br />ADDRESS <br />j SIGNATURE_y1 it y DATE <br />EH230038 (revised 02120/09) <br />1 <br />