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ENVIRONMENTAL- I-TEALTH 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 /> 7111 PERMIT EXPIRES W DAYS FROM THE APPROVAL DATE NOICATE PERMIT'TYPE11 BELOW <br /> UTANK RETRORT U°IFING REPARmmoRr �L m REPAIR/RE[ROFlT <br /> F EPA Site# Pmject C:urtart&Telepho - <br /> A <br /> C Facaity Name Phone# <br /> I Address - <br /> L <br /> TCross Street <br /> Y owmerfOPeratnr Phone# 3 <br /> rA ame Phone# c3 <br /> ._ CA Lic# <br /> R <br /> IglorkComp# <br /> ian's Certification NRunber Expiration Date <br /> 's Certification Nlmrber - E)gmfion Data <br /> Tank m# Tank Sim Cu Chemicals <br /> ty k��Y Dale UST Instilled <br /> K <br /> P L-vWpmved V--VPmved with conditions UD'sappmved <br /> L (See Altachmnt Wdh Conditions) <br /> A <br /> N Plan Reviewers Name Apqg� pate <br /> 1 <br /> APRJCAN7 MOST PERFORM ALL.WOF*CLN. ZfrT .SAN..1 OtMOUNTY.OFfW0JQSS.SrATELAwF&.f0—P (lEs ANDR9G LJ[JX%MCFSMl <br /> ,OACILM COUNTY.EI4VIRONWWAL WEALTH DEFPWTNEtFr.OMER OR LK845ED AGEta S SIGINATIARE CERIFES THE FOLLCM43- 1 COY THAT N <br /> TiE S OF THE WUW FORWHICH TF¢S PERMrr IS ISMED,ISHNI_NUT'EIWLOY ANY PERSON V4 SICi7 A MAM ASTOTAME Sl$IELT TO <br /> Vlpt TIO!LAWS OF CALIFCRI D OJNfRACTIORS 3YRB43 OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOV44a 1 CERTIFY <br /> THAT NT}E OFTHE W5fK FOR WHICH THIS PERMTr IS MIH I SHALL EMPLOY PERSJNS S-ELECrTO MRKHiS COMPEt4SATION LAWS <br /> Tdie Db. <br /> BIWNG RMATION: <br /> Indicate the responsible party to be baled for additional EHD staff time expended beyond permit payment coverage per tank If <br /> the party designated below is different than the permit appf e.g. property owner. the party must adahowledge this ' <br /> responsibi 'foj the baring by signs and date below. /A <br /> NAME /_ / TITLE / PHONEi j� <br /> ADDRESS <br /> SIGNATURE <br /> EH23DO38(revised aWDS) . <br /> 1 <br />