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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN 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 TYPEBELOW <br /> UTANKI ' <br /> RETROFIT UPIPING REPAMEtROFiT kioc REPAIR/RETROFIT <br /> F EPA Site A Pmjed r"d,d&Telephone# dG' - <br /> G FacOtly Name 4) - PQD Phone# <br /> I <br /> L Address WC) cd <br /> TCross Street <br /> Y Owner/Operator - Phone# 202 _ <br /> Contractor Nam NamPhone#e <br /> O <br /> T Contractor Ad th 04 CA Lic# Class <br /> A Insurer y'4e-{-Or" - Work Comp#. PA2115217 76Lt <br /> C ICC Tedmioan's Certification Number Exlwation Data <br /> T <br /> D <br /> R ICC InstaNels Certification Number Elpuation Nde - <br /> Tank ID# Tank S¢e Chemicals Stored Dale UST Installed <br /> Correnty/Previolsy <br /> T <br /> A <br /> u <br /> K <br /> P LIApproved Proved wft conditions UDsappmved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT M' PERFORM ALL WORK KAOCOMAN.E INIMI-9N COLOITY.OMDINANC S.STATELAM.,AMU ILES AEDREGULATIONS.O SAN <br /> nR LIC <br /> JOAOUN COIRSFY,ElJ✓ AL HEALTH DEPMrMBdi.O1MR92 OR LICBJff-D A(87PS SK�N�TIAiE CERTIFIES THE FOLLOVRIG: 9 CERTIFY THAT W <br /> TIE PERFORMANCE OF mfa&FOR WHCH TMS PERMIT S LssuG:II9,AL NOr EMPLOY ANY PERSON W SUCH A MANNER ASTO BECOME SUBJECT TO <br /> WOR1�S C01P'ENSA LAWS OF CALIFORNIA' CONTRACTORS HRIWOR%0DONTRACIING SIGNATURE CERTIFIES THE FOU W W43: '1 CERTIFY <br /> THAT INTFE PHiF OF THE WORK FOR 11*00i THIS PERMIT IS ISHALL EMPLOY PERSONS SI&ECTTO WORKERS TION LAWS <br /> OF CAL1F'OR!'U0.' � � <br /> Awr�SMIRLM rem lll7�� 2 U <br /> SIWNG 1 MATION: <br /> Indicate the responsible party to be billed for additional END staff fine expended beyond permit payment coverage per tank If <br /> the party designated below is different than the permit appfRaA e.g. property owner, the party most admow"e, this <br /> responsibility for the billing by si n tl)re and date below <br /> . <br /> ,{�� 27'7 <br /> NAME A) `i"L-e <br /> ADDRESS <br /> 6/1 <br /> SIGNATURE / <br /> EH23DO38(revised 8/SM) <br /> 1 <br />