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ENVIRONMENTAL 'HEALTH DEPARTMENT F <br /> SAN JO.A QUIN COUNTY <br /> 600 Eaat Main Street,Stoekton,California 95202 <br /> Tal,Pbonc. (209)468,3420 Fax, (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETRtDM OR PIPING REPAIR PERMIT <br /> THis PERMIT w(PIRf1 YRR IF APPROVALDATE, NDICAn PERUIT'YArRFLOW <br /> QTANK RETRCMT PINQ AEPAT DULIC 1ZI7PAtRIRE7RDF1T C1UOLDS <br /> AHTISVR UPORAVE <br /> F EPA 9lte Il" I Ptu)efl Contact&Teiephnne# ` E f [/-8 <br /> A <br /> Far�lriy Name Phone# .may. <br /> LCJ*f <br /> �tadress <br /> T crcvsa Street � <br /> y Clime pram 1 . . 4 phvrTe,Lt Z'b ". Gpl k <br /> o Contractor Narrre <br /> 1" Corkractor Addr2s8 50 U g,eA4 CAS Llc iCp/ d GlassI . <br /> A ItlBurtar Work Comp*-cg eC r. Z— <br /> TEalplr�tlan Dnte.. 6'? <br /> ICC Teohnlelbn's Cq�rt[Acatlan Num er..,$`z <br /> R ICC inbt;i{Jer's C®rtlAOdtion Nurnher � ..� 2�� �.rePlrpt[on D�t9 /b <br /> Ci,em tela 9f4irciQ <br /> lank ID# Tank Sze C LINY Data US h.,;Wed <br /> T <br /> AI K�f <br /> N <br /> K <br /> P 5APPMvad KApptoved with condlfions ❑CYa pprovod <br /> L 9eeAttachmn. WlthConditions) <br /> A <br /> 1PInn Reviewers Nems <br /> APPLIbgAi7 LtU9I PERP OAM ALL RiS IN ACGORCANCE WITH SAN JOACIVIN COUN?Y CRPINANCE9.STATE LAVr,AND RULBa ANO REGULATTON9 OF SAb <br /> JOACUtN COUNTY,EMANCRIlm L HFALTH Dl PARTmaKT,a4N, QR OR LICRNM A0914T'S SIM07UR6 CQATIFIES THE P(]LLQtMN4; 'I CI!ggrPv THAT IN <br /> THE PSRPIPPMANC5 OF THE) ICH TH9 FV1MIT M ISSUED I SHALL NOT EMPLOY A10 PEA80N[N SUCH 9 MANNER AS TO BECOME @UBJPCT T'O <br /> woftatEfra c0 F C C4NTRACTOW$AIRINC Oft SU9CaNTRACTIND SI(WATURE CERTIFIRS THe FOLI•CWHG: ^I CERTIFY <br /> THAT IN THE P -OPMAN B OF AMORIK FOR YUHICH THO PERMIT 19 ISSUED,I SHALL IPAPLO'P6A90NO AVIRJeCr TO Vv0RKZR'3 6OMP12NSATION LAM <br /> OF cALIFORNIA, <br /> Ap lours 4 naruro7+u� B o` _^ 12 �! <br /> SIDING INFCIRMAION; <br /> Irrdlcato the rstponslNe!party to be billed for additional EHO staff time expanded beyond permMt payment covotage per tank, If <br /> ne party deslgheted below Is di%rAnt than the permit sppllcorrt, o,g, property q.PMgr, the pAr1Y rnUst acknowledge thta <br /> resportsVltfy for the billing by signature and dpte below, <br /> KA d � l 'VA Tin r-Lq PHONE11: _Z0.9. ,a,�C)kOt Iq <br /> A.DARESS /el, ,-2 TFC r <br /> i <br /> SIGNATUR <br /> EK23DO38(reelsAd 12131W) <br /> - = 'HILI SSE] U coca <br />