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09/26/2008 FRI 16:47 FAX 2094433 SJC EHD 0002/007 <br />ENVIRONMENTAL HEALTH DEPARTMENT; ; _�'I `i' r-' Ill <br />SAN JOAQUIN COUNTY NO 21 4Z008 <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />,•{�, i Y w1 t <br />a= r it z` <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVALtj DATE. INDICATE PERMIT TYPE BELOW: <br />UTANK RETROFIT UPIPING REPAIR/RETROFIT �_JUDC REPAIR/RETROFIT ,COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name <br />Phone # <br />IAddress <br />Q� <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone n <br />cContractor <br />Name <br />Phone # 4 <br />0 <br />N <br />T <br />Contract r Address CA Lic #� Class <br />Insurer Work Comp #` <br />A <br />TICC <br />Technician's Certification Number Expiration Date <br />R <br />ICC Installer's Certification Number Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored Date UST Installed <br />Currently/Previously <br />2 <br />T <br />A <br />N <br />K <br />P <br />pproved with conditions UDisapproved <br />UApproved XeA�tAtachment <br />L <br />A <br />S With Conditions} <br />w <br />N <br />Plan Reviewers Name /l/ Date_,'/v <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIR NTAL HEAL PARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE HE WO FOR ICH T PERMI7 IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMP ATION LAW OF RNI CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PE O NCE OFT E RK OR HICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA.' 6 <br />�� <br />Applicants Sign Till. Date '� '►�] <br />i BILLING INFORMATION: <br />Indicate the responsible pto a billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated belo 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 />1 <br />