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�, s <br />R ENVIRONMATAL HEALTH DOARTMENT <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 REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br />F <br />EPA Site # �2�,�� <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name C� ,� <br />Phone # <br />I <br />L <br />Address -1(7—,S <br />I <br />Cross Street <br />T <br />Y <br />owner/operator <br />Phone # A% LAL <br />oContractor <br />Name Y <br />Phone # a k tl q b,� <br />T <br />Contractor Address` - <br />CA Lic # r Class <br />AInsurer <br />Work Comp # <br />Q <br />T <br />�ICC Technician's Certification Number � \\ e - <br />Expiration Date b <br />RICC <br />Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Date UST Installed <br />Currently/Previously <br />T <br />A <br />N <br />K <br />P <br />❑Appr ved Approved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />''11 <br />Plan Reviewers Name AJI(Date 2 U <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WIT SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. WNER OR LICENSED AGENT'S 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 TO <br />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 />Applicants Signature, Title i Date 1310 <br />BILLING INFORMATION: V I <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 <br />SIGNATURE <br />EH230038 (revised 12/31/07) <br />TITL <br />1 <br />HONE # <br />