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15 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 tqEj(;k1VjiL) <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AR 02 91w, <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: UFAIr <br />Q TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br />,>40 <br />F <br />EPA Site # <br />Project Contact & Telephone # i (� <br />� <br />FacilityName ( <br />Phone w� <br />I <br />L <br />Address P50/ ' <br />TCross <br />Street <br />Y <br />Owner/Operator <br />Phone # <br />c <br />Contractor Name f pa;i; jr,2�l l <br />Phone #� <br />N�� <br />T <br />—�' <br />Contractor Address <br />CALic# Class <br />RInsurer <br />A <br />Work Comp # <br />T <br />ICC Name <br />- INa <br />� <br />t <br />Expiration Date - I <br />Technician's <br />R <br />ICC Installer's Nam® <br />Expiration Date. <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(I.e. 87 piping sump, 91 leak detector, UDC in, etc.) <br />A <br />N <br />K <br />P <br />❑ Approved <br />pproved with conditions ❑ Disapproved <br />L <br />e Attachm With Conditions) <br />A <br />N <br />Plan Reviewers Name <br />Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />JOAQUIN COUNTY, ENVIRONME EALTH DEPARTMENT. OWNER OR <br />THE PERFORMANCE OF TH RK FO WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />"I CERTIFY <br />WORKER'S COMPENSATI LAWS CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />THAT IN THE PERFOR CE OF T WORK FOR WHICH THIS PERMIT IS ISSUED, I S ALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." <br />Date L. <br />BILLING INFORMATION: <br />r <br />Indicate the responsiblty 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 signat and date below. r, —7-7 500%� <br />NAME <br />f IZ t 0 _TITLE � (.t.� PHONE .. t t G_. <br />'kDDRESS <br />EH230038 (revisec�12-11t1SY' \ 2 <br />