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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN COUNTY <br /> 304 East Weber Avenue,Third Floor,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 PERMTTEXPIRFS SO DAYS FROM THEAPROVAL DATE WDICAiEPERMIT TYPE BELONG <br /> UTANK RETROFIT UPIPING REPAWRETRORT UDDG OFlT <br /> F I EPA Site# Pmjed Canta3& <br /> A Telephone# <br /> C Facility e Nam <br /> I t Phone# <br /> L Address F - Z <br /> I <br /> r Cross Stmt <br /> Y Owne90peralo - -Phone If <br /> G Contractor N <br /> N Phone III <br /> - �? <br /> T Contractor ss CA Lic# <br /> R I U Class /i t z <br /> A work comp ////� <br /> T ICC Technician's Certification NtImber <br /> Expiration Data <br /> O <br /> R ICC InstalleYS Certification Number Expiration its <br /> -- Tank ID III - Tank Sim Chemicals Stored Dal.UST.IrmtaBed <br /> Canenty/Previously <br /> T <br /> A <br /> u <br /> 1K <br /> p UAppmved �6pproved with conditions - UD'aappmved <br /> L (Se=n' ions)NPlan Reviewers Name <br /> APPLICANT MUST FERFORM.ALL.WORK INACCOROAK1—r=M..saN.CmUE1CQrnYARO=ne1( S.siATE nenEllES nto.RMLLK wN,S..OF SAN <br /> "OM CCU" EWRON E?JrAL TEALTH DEPARTMENT.OM4ER OR I.KEUSED AGENT'S SNQFS,. r CERTIFIES THE FOlON D �CERTIFY THAT W <br /> THEPSU;DRMANCECFTHEYICWFCRV"CHTEASPER)KrS MIED,ISiNLNOTEMPLOY ANY PERSON IN MICHETIFIE AHE FOLIER ASTOB[WMEIFY THAT <br /> TTIN <br /> TRATVJOFIN TI CCMREf1Sq lANS OF CN-ffA2NUl' �NiRAC(62'S HIRINGOR S BDONTRACT24S SIGNATUTE CERTIFIES THE WLLOvejG 'I CERTIFY <br /> 7FU1T W'tl-E OF THE NIC431t FCR NMIOi 71iI5 PBtYTTSLSLED.ISHALL EMPLOY PERSONS SJBECr TO WORKERS COMPENSATION LAMS <br /> �CALIMBA' Ii $ 7 <br /> Appfie�SghaWe Iy TdL �r �r tie l/ r�� <br /> BILLING( TION: <br /> Indicate the responsible party to be trolled for add-&nal RID staff lone expended beyond permit payment coverage per tank if <br /> the party designated below is different than the permit appfiant_ e.g_ property owner. the party must acknowledge this <br /> responsibility/e ibilling by sigpnlature and date below. <br /> NAME I(1 � / ! 0� TITlS <br /> ADDRESS -L56- <br /> SIGNATLIRE <br /> EH23DO38(revised 80W) <br /> 2 <br />