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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQHN COUNTY <br />304 East Weber Avenue, Tkird Floor, Stockton, California 95242 <br />Telephone: (209) 468-3420 Fax: (209) 458-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />I I <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL LATE. INDICATE PERMrr TYPEW.. <br />BELO <br />UTANK RMORT -JPiRNG REPMIRETROFIT LJUDC REPAIRME ROHT <br />F I EPA Sit-- # I Pmt Contact & Telephone # <br />A r <br />C Facility Mame \ Y1A, Phone # <br />L Address 40 , c• <br />ICross Street <br />T <br />AP"-IGANT MUST PE WORM ALL VAORK KA APIA VYrM S/1G J3kQ= OaZITY ORDNAUC ES.,.STATE LAVIR.S . AM R! It AND-RE�TIMS OF SAKI <br />"CUN CUL Y, EWRC]WEUrAL HEALTH LEPARTMENT. OA&IER OR LrBISED AGE4M SISI ATLRE C OMFIES THE FOLLCVJM: -1 CERTIFY THAT IN <br />THE PERF0 MANGE OFF THE WORK FOR WHCH THIS PERMIT LS SSaL , I SHALL NOT EMPLOY ANY PEI29 IN SUCI-m A MANNER AS TO SE03ME SLCJBi , TO <br />WORKER'S Ct7MPENSATIC]N LAWS OF NTRACTORS HIRING OR SUBDONTRAC M SKYNATURE CERTIFIES THE FOLLomga "I CERTIFY <br />THAT IN T}� PERF MANCE CF THE:-41RIRJ(, WH'Z CUTHIS PERMIT IS I SHALL EMPLOY PERSMS SUeJECr TO YK]RKER'S COMPENSATioN LAWS <br />APPS Sgnai�e-✓'Qr-�°.� `" T"� <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff lime expended beyond permit payment coverage per tank If <br />the party designated below is different than the permit applicant, a -g. property owner. the party mast acknowledge this <br />responsibility for the billimj by signature and data below- <br />'-4- <br />elow. <br />TITL� t'HONE # � � C <br />J <br />EH23D038 (revised &W%) <br />-00 <br />perator <br />Phone # <br />r flame <br />Phone # C1or <br />Address G- �_CA <br />`,ti5 <br />W <br />tic # Class <br />-t <br />\Work <br />Comp # YFmician's <br />motion Plumber <br />firatiorm Damller's <br />Certification Nuumber <br />E*wation Data <br />Tank ID # <br />Tank Sire Chemicals Stored Date UST Instated <br />Cunently/Previousty <br />T <br />A <br />M <br />K <br />P <br />L]App--d <br />proved with conditions UDisappmved <br />L <br />A <br />{ Attachment With Conditions) <br />N <br />Plan RevievNets Name s.��'V�. <br />_ Dale <br />AP"-IGANT MUST PE WORM ALL VAORK KA APIA VYrM S/1G J3kQ= OaZITY ORDNAUC ES.,.STATE LAVIR.S . AM R! It AND-RE�TIMS OF SAKI <br />"CUN CUL Y, EWRC]WEUrAL HEALTH LEPARTMENT. OA&IER OR LrBISED AGE4M SISI ATLRE C OMFIES THE FOLLCVJM: -1 CERTIFY THAT IN <br />THE PERF0 MANGE OFF THE WORK FOR WHCH THIS PERMIT LS SSaL , I SHALL NOT EMPLOY ANY PEI29 IN SUCI-m A MANNER AS TO SE03ME SLCJBi , TO <br />WORKER'S Ct7MPENSATIC]N LAWS OF NTRACTORS HIRING OR SUBDONTRAC M SKYNATURE CERTIFIES THE FOLLomga "I CERTIFY <br />THAT IN T}� PERF MANCE CF THE:-41RIRJ(, WH'Z CUTHIS PERMIT IS I SHALL EMPLOY PERSMS SUeJECr TO YK]RKER'S COMPENSATioN LAWS <br />APPS Sgnai�e-✓'Qr-�°.� `" T"� <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff lime expended beyond permit payment coverage per tank If <br />the party designated below is different than the permit applicant, a -g. property owner. the party mast acknowledge this <br />responsibility for the billimj by signature and data below- <br />'-4- <br />elow. <br />TITL� t'HONE # � � C <br />J <br />EH23D038 (revised &W%) <br />-00 <br />