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• <br /> ENVIRONMENTAL HEALTH DEPARTME#jRM T <br /> SAN JOAQUIN COUNTY EX�,ID <br /> 304 East Weber Avenue,Third Floor,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 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑TANK RETROFIT IPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# 2d —c l et 6 0 j U <br /> A <br /> D Facility Name ' L—y S Phone# <br /> L Address I LA S S. 9 -4 e J <br /> TCross Street <br /> Y Owner/Operator Ulk ,-. Phone# <br /> C Contractor Name S Phone# <br /> 0 <br /> T Contractor Address v �J1� CA Lic# SI Class /� J <br /> A Insurer ` Work Comp# <br /> T ICC Technician's Certification Number J01 Expiration Date <br /> RICC Installer's Certification Number , Expiration Date <br /> Tank ID# Tank Size emicals Stored Date UST Installed <br /> Currently/Previously <br /> r £" b <br /> T <br /> N <br /> K <br /> P ❑Approved pproved with conditions ❑Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name ate <br /> h! U1 Ir-7 <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: "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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicants Signature Title14� " Date11 0--7 <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 by signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH230038(revised 8/8/06) ON 1i0o <br />