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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQU N 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 PERMIT EXPIRES go DAYS FROM THE APPROVAL DATE,INDICATE PERMIT TYPE BELOW <br /> UTANK RETROFIT UPIPING REPARIRETROFIT U=REPAwRETRoRT <br /> F EPA Site i Project Camad&Teleptmne i <br /> C Facility Name Phone i none <br /> IAddress <br /> L <br /> T cross sTreet Phones 917340- <br /> y OwnerA>perator Ptnrne i �� T <br /> Go Contra <br /> N Contra r SsCA tics Q '�" lJ �• <br /> T / VYork Come i lx f <br /> R Irrsu <br /> A <br /> C ICC T - 's Cation Number Ea tion Data <br /> T <br /> R RCC bT4aws.Ceftis ation Number - E,#abon Date <br /> Tank Sine Chemi ails Stored Dale UST Installed <br /> Tank ID i Gu nenlly/prcMusly <br /> T <br /> A <br /> N <br /> K <br /> P LIAppmved 1Armmved viiBT conditions UDisappnoved <br /> L � (see Aftadmnt With Cond"dions) <br /> o <br /> N Plan Reviewers Nart Date <br /> APPLCAW MUSTPERF-ORM.ALL MXOEKN.A(?CCRDANMWWSAUJaBa$RCa"rY. _ UICES.SLATEI.IUAL'.:ANDFI.IES AIB-RIDGUAWNS:CF SAN <br /> JOACUN COUNTY.ENVIRONMENTAL HEALTH OG3P MBTT,OANFR OR LIORISED AG84M SGNATIJ RE CERTIFIES THE FCLLONBC -1 CERTIFY THAT N <br /> THE FERFaRMANCE OF THE WORK FOR VNiCH7FOS PERMIT coNn IS ASSZIDfiRM ORAS REMPLOY ACING PERSON HTU�CERT6�THEETf 'I ro <br /> wafao3ts cor8sas4 LAWS OF CALFOfd'AA.- CONfRACTOIRS <br /> 7FU1T N 7}E OF THE VV VM FOR V*WH THIS PERMIT 6 MM I SWLLl EMPLOY PERSONS SL8-EC7r NR7f21(ERS COMPENSATION LAWS <br /> OF CAtJFORtIIA' <br /> hyS�r,Sg�+e <br /> Tele � <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be belied for additional EHD staff fine expended beyond permit Payment coverage Per tank If <br /> the Parrf4ty�na <br /> led below is different than the permit e.g. propertyowner, the Party muusst aacbrowledge this <br /> Fespon The blfirrg by 5 d date below. <br /> TI PHONE i <br /> NAME <br /> ADDRESS <br /> I/ <br /> SIGNATURE <br /> ER23DO38(revised 878106) <br /> 1 <br />