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.. �� ..,. " ,• . K Y.. P P Y w P A R rp 7 R 1 M i p f �+ Tse' a. . A 1 Y. P 1 r w M r. w P 1 Yr x,+, . <br />} � 1d`w V- /ipl k Y MY� Yltl p'�y �; .,�1 ,kf{»; .p. 1. M P' ► ', Rt{ill <br />'Vi <br />,t <br />I <br />I P { ii _ Y <br />B <br />sENVIRONMENTAL HEALTH DEPARTMENT <br />€ SAN JOAQUIN COUNTY <br />P <br />_ 600 East MainStreet, Stockton, California 95202- <br />1 Telephone: (209) 468-3420 r -ax (209) 468-3433 <br />` APPLICATION FOR UNDERGRdUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />1THE <br />PERMIT <br />0 TANK RETROFIT 0PIPING REPAIR/RETROFIT TD UDC REPAIR/RETROFIT <br />D COLD STARTART/EVR UPGRADE <br />F EPA Site # Project Contact & Telephone..#. <br />c Facility Name L Phone <br />I Address ' <br />T Cross Street _ _ <br />Y Owner/Operator Mrn Phone <br />C <br />0 Contractor Name <br />Phone # <br />7 Contractor Address CA Lic # <br />R 4ii�L Ciasslts� �� <br />A Insurer <br />d Work Comp # <br />cICC Technician's Name <br />T Expiration Date <br />R ICC Installer's Name <br />Expiration Date <br />Tank system work area Tank Size Chemicals Stored Currently Date UST <br />(Le. 87 piping sump, 91 leak detector, UDC 1/2, etc.) Installed <br />T <br />A <br />N <br />K <br />P ❑Approved Aft/a <br />pproved With conditions ❑ Disapproved <br />A (S ent 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 REGULATIONSd <br />JOAQUIN, COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <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.SUB <br />WORKER'S-COMPENSATION'LAWS Off CALIFORNIA." OONTRACTOR'S.HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I THAT INrHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEDI SHALL EMPLOY PERSONS SUBJECT TO.WQRKER:S CQMPENSATIO <br />OF CALIFORNIA" <br />Applicant's Signature Tltie - Date <br />B:ILLIN.G. 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 belling by signature and date below, <br />.__ <br />Wh <br />NAME t1s_CL(°h(1"j��iCx(�I�TITIL 1���.) PHONE# <br />_._.. <br />_._ <br />-ADORESS <br />v� <br />SIGNATURE --(LL1 DATE <br />EH230038 (revised 08/1/11) <br />