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F <br />A <br />C <br />L <br />I T <br />Y <br />is <br />' O <br />N <br />R <br />C <br />O <br />R <br />T <br />A <br />N <br />K <br />I <br />P <br />L <br />A <br />N <br />0 0 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 <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 BELO', <br />TANK RETROFIT PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT COLDST <br />— -- <br />L EPA Site # - � _ <br />Protect Cor;tact $ Telephone # <br />Faculty Name <br />Address _ <br />Cross Street <br />Owner/Operator <br />Contractor Name �- <br />------------- <br />t' c l <br />Contractor Address —� <br />Insurer <br />ICC Technicians Name <br />ICC Installers Name <br />k- _ <br />Tank system work area <br />_l. 87 p.p;rai ea.]t eanr <br />Approved <br />Plan Reviewers Name <br />Cc% <br />r <br />Tank Size <br />Phone <br />/EVR UPGRADE <br />Phone <br />— <br />CA LIc c?c Class lr '1 4 <br />Work Comp # <br />Expiration Date n <br />Expiration Date <br />hemicals Stored Currently Date UST <br />- Installed <br />AP oved with conations <br />(See Atta ment With Conditions) Disapproved <br />ISODi ;r -- <br />rttttORM ALL, WORK IN ACCORDANCE VVITH <br />�JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT Oc <br />iTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br />(WORKER'S COMPENSATION LAWS OF CALIFORNIA C <br />' CONTRA <br />;THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 7 TR PE <br />OF CALIFORNIA' <br />Appilrant's Signature / <br />Date <br />3AN JOAQUIP, COUNTY ORDINANCE <br />,'N CR UUENSED AGENT'S SIGNATURE T ERAwS .T R„LES AND REGULATIONS OF SAN <br />r UED I SHALL NOT EMPLOY AN' E C, RT F'ES HE FOL OWING 'I CERTIFY T <br />HAT ;N <br />N PERSON ,N SUCH A MANNER AS 'O BECOME SUBJECT TO <br />r R'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLQvVING <br />MiT IS ISSUED I SHALL EMPLOY PERSONS SUB,:EC. �O'.NORKER' 'I CERT;FY <br />S COMPENSATION LAWS j <br />T,tle <br />the party designated below IS Indicate the responsible party to be billed fora itlonBlE}�Ip Gaff INFORMATION p nI� d beyond permit <br />responsibility for the billing by signature <br />and fferent an/the <br />netbelw permit applicant e <br />P 2 payment coverage per tank It <br />g prcpeRy owner. the party must acknowledge this <br />NAME <br />TITLE <br />ADDRESS ----_PHONE # <br />SIGNATURE — ----- <br />EH230038 (revised 07-17------------------- <br />- <br />