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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95242 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THS.PERMIi EXPIRES W DAYS FROM THE APPROVAL DATERDICATEPERM ,WERELOW <br /> LJTANK OAT L11IPIPING REPARAtEROW LkiocREP <br /> F I EPA Site# Project Contact S Teleotmne# L <br /> A <br /> C Facility N e <br /> I Phone# <br /> L Address 7 <br /> 1 <br /> r Cross Street r �' <br /> Y O e A4�aro` 1 z Phones <br /> G Contractor N ` <br /> Pho <br /> N ne# <br /> T Contractor <br /> A Insurer i <br /> T wad(Comp# <br /> ICC Tedmiaan's Certification Number <br /> T <br /> O Explmtion Date <br /> R ]CC Installws Certification Number F ation Date <br /> Tank ID# Tank Size Chemicals Stored <br /> Curnently/Previoasty Dale UST Installed <br /> T <br /> A <br /> u <br /> K <br /> L +PProved 1V6mied with cacrddrorrs UD'sappmved <br /> A (See Attadment Vft Conditions) ry <br /> N Plan Reviewers Naar_ V✓)' IV (7/t^ Date_ r} <br /> APPLICANT"I 14 PERFORM N1.LSORK¢3A[YYnner.rr a .SIAIE /ICQBIE�S AED <br /> LCBSlIDm GENTS SGNAS R_ . LAN6,_ ._ .RE(_�IAAACHS..CF SAN <br /> THAQAN cLMfY,ENVbTOI Y W F HEALTH THIS PE <br /> S ISSUE I I e'zuEn ALS SGTNTIAiE C8277F6 THE FQ10J1BG C�tI&l'THAT IN <br /> THE PEldSROMPEWATKW LAAS FO2YNiC71 T76S P9iIAT S ES�13T,I SFiNLNOTEYPLOY ANY PERSON IN S CH A MAMEMR ASTOB3'JJMESIBECT TO <br /> THATIN25 CCAPE3.ISAT7pN LAMS OF CONTRACT HIR!(J�OR SALON RAC17ING SIGNATURE CBRUnFiES THE 7 C6iDr'Y <br /> ff CA(JFORf•➢0.T IN THE PERI`C�¢T `HE Mt THIS PERMIT i .19iALL=- <br /> N: <br /> S$ECf TO TpN LAMS <br /> e !-2BIWNG 1 RMATIO <br /> Indicate the responsible party to be baled for additional EHD staff fine expended beyond permit payment Cooerage per tank If <br /> the Party designated below is ddferent than the permit apprrcaA e.g_ <br /> respon lityy' the bafirKrt by signature and date below. Pr°pedy owner, the party must adarowledge this <br /> NAME 1 'TIT,tL,E, lL r( ?W, <br /> ADDRESS <br /> SIGNATURE <br /> EHP30038(revised 1tllM <br /> 1 <br />