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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone: (209)465-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL GATE INDICATE PERMIT TYPE BELOW <br /> ANK RETROFITUPTPING REPArV ,REfROFIT t UDC REPAIR/RETRORT <br /> —� <br /> JT <br /> F EPA Site i Project Contact&Telephone ( I <br /> � Facility Name Phone i <br /> IL Address <br /> ICross Street <br /> T <br /> V Owner/Operator 1 y <br /> J Phone i <br /> 0 <br /> Contractor Name Phone i <br /> N Contractor Address , CA Lic i Classy. <br /> 7 <br /> Insurer I I - ' ,l Work Comps p <br /> C <br /> T ICC Technician's Certification Number Expiration Dab <br /> G <br /> R ICC Installses Certification Number Expiration Dab <br /> Tank ID i Tank Sime Chemicals Stored Dab UST Installed <br /> Curently/Premously <br /> T <br /> A <br /> N <br /> K <br /> P UAppmved UAppmved with conditions UDsappmved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Dab <br /> APPLICANT MUST PERFORM ALL.WORK HACCOBDANCE WMTH.SAN JOAOUINOU RY ORDINANCES,STATE LAINS.AM MILES AND(ESSLATIONS OF SAN <br /> JOAOUN COUNTY.ENVRCwe4rAL IEALTH Dawn BTT.OWNER OR LICENSED AGea'S SIGNATIAiE CIERTTFIES THE Fal-CIA JC: •1 CERTIFY THAT IN <br /> THE PERFORMANCE OF wow FCRNM1BCH THS PER 6 LSSIET),I SHALL NOT EYRDY ANY PERSON IN SUCH A MANNER ASTO BECOME S EL1ECr TO <br /> NIORKHRS LAMS OF rsLlForaRw• CONTRACTORS"RW OR SIRCONTRPCTAIG SK*ATLW-CERTIFIES THE FOLLOWING 7 CERTIFY <br /> THAT W TTE CF THE VyCiM Mti TFRS PERMR S 55L8l,I SHALL E}IPLOY }/(/,r7 TO WORKERS CIMP W TIONN LAMS <br /> CF CALIFORtiA' ' 'lLl,/ '" <br /> APPS ° <br /> BIWNG INFORMATION: <br /> Indicate the le party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party nafed below 's different than the penntl a nt, e.g. props owner, the party must acldwwfedge this <br /> response I the billingbY s' n re d date below. <br /> NAME TITLE i <br /> ADDRESS I ',• 'J <br /> SIGNATURE <br /> EH230038(revised 88106) <br /> 1 <br />