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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 REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F EPA Site # Project Contact & Telephone # <br />A <br />� Facility Name Phone # <br />1 Address I LA <br />Cross Street <br />T 9.,t <br />Y Owner/Operator Phone# <br />C <br />ContractorName <br />o Phone # _ <br />N Contractor Address r <br />T A Lic # Class U <br />R Insurer <br />A Work Comp # q. ', 00 <br />T ICC Technician's Name <br />Expiration Date <br />R ICC Installers Name <br />Expiration Date <br />Tank system Work area Tank Size Chemicals Stored Currentl Date:UST <br />(i.e. e7 �s mac. si leak detector. UDC 112, etc.)y Installed <br />T <br />A <br />N <br />K <br />P ❑ Approv Approved with conditions El 'Disapproved <br />A L e Attachment With Conditions) <br />N Plan Reviewers Name <br />Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, D 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 13ECOME SUBJECT <br />TO-WORKER'S.00MPENSATION 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 />Applicants Signature_ the U . <br />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 by signature and date below. r}� :., r <br />NAMFE ` leJ �'Q C( r TITLET_ Y',r <br />�1 6 PHONE —iLU l Cly I <br />ADDRESS J�3 1hllLln�larn �R , STCJ, , �� �52U�j <br />SIGNATURE <br />DATE <br />EH230038 (revised 02/20/09) <br />1 <br />