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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQHN 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 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPEBELOAL <br /> UETRTANK RONT UT9PING REPARrtRETROFlUI <br /> T wc REPAIRNURORT <br /> F EPA Site i Pmjed Cardac4&Tekohane# C�ifl r e'Y �� a� Y/ol <br /> C Faaliy Name �,. / Phone i.2O9 _ 8 - // <br /> / f Os3=NLAdd <br /> 1 Cross Street <br /> T <br /> Y Own /Operator Ctide k Phone i <br /> C <br /> Contractor Name LN U A C Phoneiaor]- /i/- lam <br /> T Contractor Address CA Lic i (y(o pp 1](o Class <br /> A Insurer - .. Workrompi (,W '(S 177 <br /> C ICC Tedsrcian's Certification Number Expvation Data <br /> T <br /> O <br /> R ICC Installar's Certification Number F_Ipsabon Data <br /> Chemicals Stored <br /> Tank ID i Tank Size Currently/Previously [sale UST Irrsaied <br /> T <br /> A <br /> N <br /> K <br /> P LlAppmved rr 4pmved with conditions UDisappmved <br /> L (See Attaclumnt Wilk Conditions) <br /> A <br /> N Plan Reviewers Name 1/1 �{ iL �(/1^tj", Data 7/?-Lo g <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACILM DOlNTY ORDINANCES.STATE LAWS AND PLIES ACD-REQAATION5 OF SAN <br /> JOAOUN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT OWNER OR LMSED A.GENM SIGNATURE CERTIFIES THE FOLLOYRG: '1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS SSU®,l SNNL NOT EMPLOY ANY PERSON W SUCH A MANNER AS TO BECOME SPECT TO <br /> WORKERS COMPENSATION LAWS OF CALIFORNIA- OONTRACTCRS HIRING OR SIBCCHTRACTNG SIGNATl1RE CERTIFIES THE FOLLOAJNG 'I CERTIFY <br /> THAT N THE PERFORMANCE OF THE WORK FOR WHICH THUS PERMIT IS tSSLED,I SHALL EMPLOY PERSONS SUB.ECT TO NOPo(ERS COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> AppiacartsSgrsWe T - ;� w O-te -30 - 68' <br /> MILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional ERD stat[tine expended beyond permit payment coverage per tank If <br /> the party designated below is d@ferent than the peril applicant, e.g. property owner, the party must adamwledge this <br /> responsibility/for the billing <br /> /byy si-gnnyabire and date below- <br /> NAME- <br /> elow.NAME Sa.IIC EL-/./D/A. TITLE.LY,v/fICC �UYrYJY1Q ONE# RP�- 6z.� <br /> ADDRESS <br /> SIGNATURE <br /> EH23D=(revised aMM) <br /> 2 <br />