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I <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />' Telephone: (209) 468-3420 F'ax ('209) 468-3433 <br />APPLICATION FOR UNDERGRdUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT D UDC REPAIR/RETROFIT 0 COLD STARTIEVR UPGRADE <br />F EPA Site # <br />A _ - Project Contact & Tel _. t <br />c Facility Name It <br />L Address Phone <br />T <br />Cross Street • W_,`�7,�IIC� <br />Y Owner/Operator Phone # <br />C Contractor Name rt <br />oPhone # <br />NContractor Address <br />R CA Lic # Class <br />A Insurer Work Comp # <br />cICC Technician's Name <br />RT Expiration Date <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Tank Size Chemicals Stored Currently Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P ❑ Approved Approved with conditions <br />L ❑ Disapproved <br />A (S e tt nt With Conditions) <br />N Plan Reviewers Name <br />Date <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.IO BECOME SUBJECT.T.O <br />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 SUBJ.EC,T,TO WQRKERS.C.QMPENSAION LAWS::., ., <br />THAT <br />T IN T RNIA" <br />,._ <br />_.-.._ <br />A -11 --- <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 blI ing_by signature and date below. <br />61 (vet _ . _........ --- -_ <br />NAME �,.t tTE . ID N I�'E'�T�K� T(�ZS �' Ci _ <br />--�->-' !_TITLE �f1�ltlC) PHONE# <br />ADDRESS <br />--SIGNR-ro _ Ilryn t k 40 <br />EH230038 (revised 08/1/11) �� <br />