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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 /> El TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> A <br /> C Facility NamePhone# a <br /> 1 Address <br /> L <br /> TI Cross Street <br /> Y Owner/Operator c� Phone# <br /> C <br /> Contractor Name <br /> o ( Phone# _ <br /> T Contractor Address A Lic# - 0 <br /> Class <br /> R Insurer �� <br /> A Work Comp#WAW 7 00 <br /> TICC Techncian's Name <br /> T iExpiration Date <br /> R ICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 12,etc.) y Installed - <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved gApproved with conditions ❑ Disapproved <br /> L <br /> A (See Attachm nt With onditions) <br /> N Plan Reviewers Name Date .26) zz <br /> f <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 <br /> TO-WORKER'S COMPENSATION LAWS OF CALIFORNIA."CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMAJ*CZ OF THE WORK FORJ HICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA.' <br /> Applicant's Signature — _ Title_ CT � Date s <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.annlicanf o g,15rqperty owner, the party must. acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME V JLSL IN CJ TITLE_ Effn6 aym PHONE#1J�? ' I &ZJ6 <br /> ADDRESS JC��� Inll Int rn 16C T0P . 952ib <br /> SIGNATURE <br /> blonDATE 4_ � <br /> EH230038(revisea u /20/09) <br /> 1 <br />