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- <br /> �A.. ia a a saa aar.e.Aa '- ' as v e ear a R ' i ' <br /> �er# <br /> y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> k SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 - <br /> Y r Telephone: (209)468-3420 rax: (209)468-3433 <br /> i <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> f ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT ❑UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone#_ � ( X <br /> C __ _ _ - <br /> Facility Name — Phone# <br /> L Address v �� _ <br /> s /� <br /> T Cross Street - <br /> Y Owner/Operator Phone# <br /> b• - 1 . <br /> o Contractor Name Phone# <br /> N Contractor Address <br /> T CA Lic# <br /> R �_ Class <br /> Insurer <br /> A a Work Comp! <br /> ocICC Technician's Name <br /> Expiration Date <br /> R ICC Installer's Name 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 r] Disapproved <br /> A (S Attachmen With Conditions) <br /> N Plan Reviewers Name <br /> to <br /> APPLICANT MUST PERFORM ALL.WO IN ACCO NC IT H SAN JOAQUIN OUN ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEP RTMENT.OWNER OR LICE GENTS 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 TOWORKER'S-COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT INTHE PERFORMANCE OF THE WORK FOR WHICH THIS,PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS.. <br /> of cauFORNIA <br /> Applicant's Signature Title _ Date 61_26 IBJ <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 /> __._ <br /> NAME / L�.[_TITLE_ ale fQ AJ n PHONE#--2- <br /> _ ADDRESS 26)C 5 ) (�:)�l�l��'✓(li1 �1 P�IV�a._- ����Ti��,�(1(�Gj-���j _ r� <br /> SIGNATURE I�M�kNsk 14f) DATE <br /> EH230038(revised 08/1111) <br />