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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)468-3410 Fu:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TICS PERMIT EXPIRES W DAY'S FROM THE APPROVAL DATE R"Cl1E PERMIT TYPE <br /> ff BELOW <br /> UTANK RETRORLT nPaIG REPmRERROFtT L�REPAWRERORT <br /> F EPA Site 9Prcject Contact&Telephone S <br /> A Faoliy Name <br /> L i Pbone A o20�9 ql7?- <br /> G)S2%Cl <br /> � Address CIA <br /> L <br /> I Gross Street [, <br /> T <br /> y Owner/Operator 1.11 <br /> C Contractor Phone f 7 <br /> ' <br /> O - g Class <br /> N Contra r ' <br /> T Work COMO2 1117 ''?; a <br /> R <br /> A Insurerr <br /> c ICC T - - •s certification Nrmlber E�cation Data <br /> Expiration Ditto <br /> O IGC Installer's Certiicaton Number <br /> R <br /> Chemicals Stored <br /> Dale UST InstalledTank ID i Tank Size currently/Previously <br /> T <br /> A <br /> u <br /> K <br /> L�PProved gppmved With <br /> conditions - UDsaPProved <br /> L (See AtEa nt Cocditions) O I <br /> N Plan Reviewers Name Date ll <br /> euYWTHSAN JOAQLWCAOL"Tl'., Nc-Fc._SLATEL"JS-AMRULES AWREGUILATIOMS:rF SMAPpLL,AtdT MLL4 PERFORM ALL 16CYtK L1.1CYY'/x�- .. - CRO _ TFE FUlOAI@G: 'i C9TnFY THAT N <br /> ,pgOIAN CQRQTY,EJV6 ONME STAL LE/LL.TH DEPARTMENT-OAHE R OR LIONSED AGENTS SIGNATURE CJ TW93swr <br /> THEPERFORMANCEOF THE VA7FLC FORY1�iICFi7F6SR�T FiRNGORSffi RAGTAiGNTl1CHntTWT 'CERTIFY <br /> � <br /> V LAWS OF CALIFORNIA.- Si$ECTTO WOPoCEts�Mp@.tSAT1ON LAWS <br /> THAT N ThE OF TL¢N/CRK FOR W-BD{THIS PERMIT Is LSSLID.I SHALL Ef6lAY PH250K5 /' <br /> CF A' o '7 <br /> ALL—TA e <br /> Indicate the responsible party to be biked for additional EHD staff fine expended beyond Permit Payment coverage Per tank If <br /> e. <br /> designated below is Qdferent than t <br /> an he Permit aPPricaat, . Property owner' the Party most achum$edge this <br /> the Party esg g - <br /> responsb(/ft for the billing by signa/hne and date below. <br /> NAME I iir�i/,p f!/1���/I/l2 -n ) l/!/l PH�tON�EO <br /> ADDRESS <br /> SIGNATURE <br /> EH23W38(revised 8181106) _ <br /> 1 <br />