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HEA <br /> E NVIR4t�IVIENTAL LTH EPARTMENT <br /> SAN JOAQUN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 45202 <br /> Telephone:(204)468-3420 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERW E KPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPEiAt. <br /> 8ELO <br /> UTANK RETROFIT UPIPING REYAPMETRORT UDC REPAIRN ETRORT <br /> F EPA Sim# Project Carta &Telephone# <br /> A Facility Name Phone# <br /> IAddress l A�M ':' `� <br /> L I- <br /> I Cross Street <br /> T Phone# <br /> Y ClwnerlOperator <br /> aContractor Narne V(" Phone#^ <br /> N ContractDr AddressX CA L.ic# Class <br /> -} <br /> R Insurer V11 Work Comp# PC)t Elbl -I- <br /> A <br /> T fCC Tectmii:aM—s Certification Number F�iration Cala <br /> R ICC krstaWs Certification Number Expiration Date <br /> Chemicals Stored Date UST Installed <br /> Tank ID# Tank Sim Currently/Previously <br /> T <br /> A <br /> it <br /> K <br /> p KpprovedL�Ifvproved with conditions UDisapproved <br /> L (See Attachment With Conditions) <br /> A / � / V� <br /> N Plan reviewers Mame Y`� `m Date i !�' <br /> p ppxJ MUST PERFO iR.AL WOW LA!ert-ORDANCE S M-RAN ja&Q=00Ub1TY.O S_-STATE LAWS.A;P—R 11. S MIS resat[`l Ar�7yLS,GF&AN <br /> "OUN OUNCY,J=Af ROf�BAB�ITAL WEALTH CERNU JEl�tT.OWNER OR Ll AGeim SI mTuRE caunEs THE Polo io- n cmmr-Y THAT W <br /> 7F>E P�OF THE WOFtIC FOR Vierra THIS PE�1�tlT!S<SS�D,I SNAIL NOT EMPLay ANY PERSON IN a)CH A UW4ER AS Ta l rE S-I&IECT TO <br /> VJOR3�S COUPENSAnGN L.AVV3 OF CAEIFORNUI' CONI-RACTOFCS W WNr'OR TRAcnNG SMATI-PE t�r]FIES THE FOLLCMR43 9 CEf7TiFY <br /> THAT IN THE PERFORL Ar+IC E OF THE VW FM FOR WHK24 THUS PERMIT IS ISMO.I SHALE.BYPLAY P SLI33.EOT To%0RlCERS 00UPENSAUM LAWS <br /> GF GgL1FORr - C� <br /> ca�rtssigrottire Td- <br /> BI-LUNG INFORMATION: <br /> Indicate the responsible party to be baled for additional END staff tine expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party roust acknowledge this <br /> responsbAity for the billing by signature and date below. <br /> TITL1 119-- PHONE <br /> IJAME � <br /> AR L <br /> SIGNATURE <br /> EH230038(revised 318W) <br /> 1 <br />