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• , L • <br /> EN-MRON ENTAD HEALTH TME Tl� i i �o►o <br /> BATA JOAQUIN COUNTY ENVIRONMENT HEALTH <br /> 601D East Maine Street,Stockton, Caffornnba 95202 PERMIT/SERVICES <br /> Tckphone: (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 n PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT CJ COLD START/E'VR UPGRADE <br /> F EPA Site# J Project Contact&Telephone# <br /> A <br /> C Facility Name Ph <br /> _Shea l 13 (o� �� Sone#--..._ <br /> L Address <br /> Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> c Contractor Name-'f4-A& <br /> it/V(UC�.1 Phone#zry��d'-1 Zk (o <br /> D -- _ <br /> TContractor Address t) w, !� "` W 5d4. b' CA Lic# Class <br /> R <br /> A Insurel��p^t� (�, Work Comp# <br /> IC-_Technician's Name J �p Z�2 Expiration Date <br /> T _• K.1�.� c ruz_ Q <br /> Q <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,gi leak detector,UDC 112,etc.) Installed <br /> A <br /> P Approved VApproved with conditions Disapproved <br /> L e Attachment With Conditions) <br /> A <br /> N Plan Reviewers Date <br /> APPLICANT MUST PERFORM ALL WORK IN CCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND RFGULAiIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY'HAT 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 SUBJEC i <br /> TO 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 SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature___ _ _ Title_ 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. <br /> NAME_____. _ _. _TTITLE_ _PHONE <br /> ADDRESS_ <br /> SIGNATURE <br /> Eh1230038(revised 02/20/09) <br /> 1 <br />