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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQU N COUNTY <br /> 304 East Weber Avenue,Tkird 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 TYPE BELOW <br /> UTANK RETROFIT UPIPING REPARmErROFrr Lkroc REPAIRmEmonT <br /> JAte i PMJ9&Cantact&Telephone i Ca,y-nom D9 G/-(o 3 3 <br /> Name " # Phone ia0q- N,5.s 70 Cf+ 95330 <br /> treet <br /> Zperatnr Pthonei�q-r/�+O '�7 �P <br /> c Contravdnr Name 1 <br /> Oe. Oar's nc, Pthore i.o209- (o l- Co <br /> T Contralvr Address <br /> (J, (� CALxi/o b07(o c� ClfO 7— <br /> R Insurer <br /> A Lti 111"O Work Comp i QW`-O/7 <br /> T ICC Tedmictan's Certification Igfion Number <br /> Exphotion Dab <br /> R ICC kTsta�s Cetti6r�on Number <br /> Ehpcaton Dab <br /> Tank ID i Tank S¢e Chemicals Stored Dale UST Installed <br /> CunentlylPreviwsly <br /> T <br /> A <br /> Y <br /> K <br /> P UAPPmved ved with cani6 M - L Dmappmved <br /> A (See Attactunmt Cothdhtions) <br /> N Plan Reviewers Name &AIA �=Dab C D <br /> APRJCAW MUST PERFORM ALL NARK N1ACCORnANCENRH.SAN JOAaMCaKry cRD=MOEs STATELAWS_ANQ01 AaD.REG[IATYDISOFSAN <br /> JOAOUIN COUNTY,E VROM MENTAL HEALTH OEPMTMEri.WA✓BR OR LKINSED AGEJr'S SIGNATURE CERi1FlFS THE FOLLOVEC 'I CER iFY THAT IN <br /> THE PEWURMAYCE OF THE WORK FOR W OM THIS PERMIT 6 ISSLIED I SHALL NOT EMPLOY ANY PERSON W SUCH A MMr HR ASTO tEODME SLALUC'r TO <br /> NORKEIM COMPE?dSATM LANG OF CALIZ "ACOM n Acrcgs HRMOR OR SUBDONIRAc NG SIONATIRE CERTIFIES THE FOLLOWTK` 'I CERTIFY <br /> THATWhE aF TfE N47RI(FORy�I�}7HRI5 PEUIIT6651ID,I SHALL EMPLOY PERSONS SIIB.ECr TO NORKBt3 cQjVNaiSAT70N LAlYS <br /> At>PSileM+e L. 6 TheJC- i Ct. <br /> BIWNG INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff tine expended beyond permit payment coverage per tank If <br /> the party designated below is ddferent Om the permit applicant, e.g. property owner. the party must acknowledge this <br /> responsbft for the billing rb��y signature and dab below_ - , / <br /> NAME ,% de, G a4 b it- TITLESIGY'UfCc(,�rM IDT� nC&! PHONE t jCj -Y(o ,373 <br /> �f r <br /> ADDRESS /A �n It71 D inn- hr. SST- T-c L`a1_( A Cl !�' -�40r <br /> SIGNATURE <br /> EH23DO38(revised BMW) <br /> 1 <br />