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01/07/2010 18:43 120° -91317 PAGE 02/02' <br /> �1- 00/00/7000 q✓Zp 1i:02T 20e4e834,l9 SJC 11D ... S6oakEoa Sery ate Rq Co 0003/00? <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 Ealet Mein Street,Stockton,CallforniA 95202 <br /> Telaphonar (209)468-3420 Fav (209)468.3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> �IiRm(T axPIRE 180 DAYS- <br /> FTAOO.NPEAPPROVAL DATE, 'NOICATE PERMIT TYPE OELOW: <br /> TANK RETROFIT PI N044'R.•£PAIWREiROFt7 0 UGC REPAIRMETROPIT 2 COLD STARTIEYR UPGRADE <br /> iF EPA 51te IY project Contact Q Taiephorle 1Y <br /> A <br /> C Faclely Name Phone b 2 — _ <br /> l <br /> Addrm <br /> TCrow atreal <br /> Y Oymodoperato ItPhone <br /> o <br /> Contractor <br /> T Cantrada Addrae . �,j- CA Us <br /> D work Gbrnp M Z <br /> T ICC Ternnlolan'a name Explrallon Date ~ <br /> O ICC Irptallpr'9 Name —I <br /> R _ _ EtpV@tlon Data I <br /> Tank* tam wont area Tank p.n v ypR.unp,MI b1 NAP,UDC m,Sul Slz , chemll Date USCbreCuremly <br /> l Installed <br /> IA yQ <br /> I N .-s } <br /> K <br /> L �ovw� — pp�Srxu'vYM wnmana ❑ Dhapproved <br /> A (Sae A 4Wlh CDndPoorta) - <br /> N Plan Ravlewels Name <br /> DmB r- <br /> APPIJGANT MUST peRFOR AMI. N ACCOnOAyOG WITH SAN MAOUIN COUNW ORDINN'OW,STATE LAWS AND RULE$AND RECULAT104S Or @AN <br /> J"04% COUNTY' WRCA=A MFiYTN DEPART 'OWNER OR LICENSED AG MTB$I"Tlll1!CERTtR 6 Tile"OuOWTNG; 1 CERTIFY THAT IN � <br /> iNa PERDORIMANZ4 OF THE WORK FOR WHICH TH18 PMWrT IS ISSU5D,I SWV.L NOT SWLOY ANY PERSON IN WON A MANNER AS TO aRCOME SU@J@di <br /> TO wOMCRN�17 <br /> ASA A'CONTPAOTt.F1921N6 oR Bl18CONTRACTTNn elOW1fUA@ CaRTIFlE9 7HS F7LCOWINO; 'I C5RTI.-T <br /> THAr IN PER, AN OF WORK r-0 THIS PERMIT m IS9UEC,I aNAf1 EMPLOY Pea3oNa 9VEJEDT TD wORYFA'@ CONDENSATION ACHE <br /> OF I:AI <br /> T10 T pRlp / <br /> 81 LLING IN MATIO <br /> indlrzle the respons@le party t0 be ollled for additional EMD start Drra axPanlOd DOWD Pennd paymori Coverage Dar tank. II <br /> :nE Darty deslgnalall 5el0w is alrrerenl than me oermll app?Cenl, 0.P. PrODOrtY Uwnaq the pony mUSI aahnnwedge. IDIS <br /> rasPonaibillty rorihe bleing Dy signature and dale NOW, p <br /> f 0rONe4_ ry/1/4/ <br /> ADDRESS O <br /> -1 <br /> Yi\ u10NA DAT5_ ,Y, ) <br /> Eh12300311(m"ina 0280109) <br /> 1 <br />