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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 So DAYS FROM THE APPROVAL DATE INDICATE PERMRT TYPE <br /> II BELONG <br /> UTANK RETRORT PIPING REPAF/RETROFTT Lim REPAIRfiURORT <br /> F EPA Site Project CmrTatt&Telenhore hi ' 7. <br /> A <br /> C Facility Name Ir * (7J Phone 4 <br /> I Address { q-70 YI LQ-Ahr <br /> R Cross Street <br /> T <br /> YOwner/Operator rC lam '{-� Plane i <br /> oContractor Name P f —63 3-) <br /> T contra rtes= — CUM r $ ob ciass /oH/12 <br /> A Insurer f'a 4(X-1 Work Comps o� <br /> T )CC Tedvucian's Certification Number Expiration Dab <br /> RIGC AnstaWs Certiication Number Expiration Date <br /> Tank ID i T2nk Size Chemicals Stored Date UST IrstaOLd <br /> currently/previously <br /> T <br /> A <br /> u <br /> K <br /> P IJAppmved red with Conditions UD'sappmved <br /> L (See Atlac)meppnt With Condmons) <br /> N Plan Reviewers Name 6tiyr"t,N:J'A" Date ho/7/Q V <br /> APAKANT MUST PERFORM.AL L WORK KAODORDANrE Vi Rr.SAN JaUl M)OMAIEY.OROtNANOESs STATE LAva;ANURLLES A6D.ROOL LAAONS. OF SAN <br /> JOwQAN OR MANC EOF THE dORK F HEALTH DEPARTMENT PERMIT <br /> GINNER OR iALL N D AGEEMPLOY <br /> PRY PERSON <br /> IN SJ OS MA NEER ASTO 7�rfffY THAT N <br /> 7}E F7#ORMNK'.E OF THE UR}dC FOR WHCH THS PFRM(T S ES,®.191ARL N7TEIriDY 1111Y PFRSW W SlX}r A YMO�H2 ASTO BECOME SBCCT TO <br /> WORICH25 N LAWS OF CJWFC'" WNfRACTORS HRING OR S BOONTRAC iNG SKYJATURE CERT FIES THE fOLLONTIG 'I CERnFY <br /> THAT N llf F'HE' IAN(f OF Tr1E 1 FOR YVHCH THIS PETRYIr IS ,R 9iALL PERSONS SUBJECT TO WORKMRS COMPENSATION LAWS <br /> IF CAUFIXiWA.' <br /> A ani Dare J d <br /> BILUNO INFORMATION: <br /> Indicate the rTth't' <br /> sble party to be billed for additional EHD staff tine expended beyond permit payment coverage per tank If <br /> the party d ed below is different than the permit applicant e.g. Property owner. the party must aCiamwdedge this <br /> responsbd" bafing bys" date bebw. <br /> NAME1 / VI G� CC _ E8Cqo�) 4lX"/ 337 <br /> ADDRESS C <br /> SIGNATURE <br /> EH230038(revised&8105) <br /> ) <br />