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ENVIRONIENTAL HEALTH DEPARTMENT <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 OCOLD START/EVR UPGRADE <br /> AF EPA Site# Project Contact&Telephone# 16 <br /> C Facility Namerl Phone# <br /> L Address <br /> I Cross Street G <br /> T <br /> Y Owner/Operator Phone# 2-69 -4 <br /> oContractor Nameo 0 Phone# <br /> T Contractor AddressCA Lic# Class AbU ,�_ <br /> R Insurer <br /> A (� Work Comp# � , l <br /> cechnician's Certification Number <br /> T ICC TExpiration Date <br /> R ICC Installer's Certification Number <br /> Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P OApproved ElApproved with conditions ❑Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N 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 /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS 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." -a `^t <br /> Applicants Signaturefym Title 1 Date 71 1 t' <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment overage 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 6M I l®0f 1,C -7 <br /> i TITLE PHONE# �, t ! <br /> ADDRESS__21�3IC1(I�Z M M C�5 <br /> SIGNATURE k Aoi <br /> EH230038(revised 12/31/07) <br /> 1 <br />