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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 EWCOLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# /i r)CC- <br /> q 4 <br /> - ^� � 1, - Phone <br /> D Facility Name v <br /> L Address 5 zcs <br /> Cross Street <br /> T <br /> Y Owner/Operator ���,- Phone# <br /> o Contractor Name I Phone# - ,n C, <br /> N -` Class `� �,t <br /> T Contractor Address �/ � �,a., '�'� CA Lic# F r j „ <br /> R <br /> A Insurer Work Comp# I� <br /> TICC Technician's Name Expiration Date V1 -1, )1,C)R ICC Installer's Name 1' Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved pproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name JDate <br /> APPLICANT MUST PERFORM ALL WOR IN ACCORDANC WITH SAN JOAQUIN COUNTOR NANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED A T'S 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 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 Title 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 ba".ture and date below. �q <br /> NAME � p�'� I {, 1, 71'f-f !r)tG G, TITLE PHONE# �"/` 3 ' <br /> } _� <br /> ADDRESS r i 0r),,. t"T. l C:p ? J ';� f� 1 a ( Ger-i` <br /> SIGNATURE i DATE / P� le,9- <br /> EH230038(revised 02/2 09) <br /> 1 <br />