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WRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQU N COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95201 <br /> Telephone:(209)468-3420 Far:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> ' II THIS PERYIfEXPIRES 90 DAYS FROM THE APPROVAL DATE BRDICATE PERMR TYPE1 BELOW <br /> L6NK RETROFTr UPIPING REPAWREfROFTf 'QL410C REPAIR/RETRORT <br /> F TEPA Sit.I Prejed Cantad&Telephone <br /> A <br /> C Facility Name �; Phone I –0 <br /> [AddressT ross StreetYwrerfOpenator Phone I <br /> C Contractor Name Phone i. ' , 3 <br /> o '` <br /> T Contra to <br /> �" CA fxI Class C– n#Z <br /> AInsurer .. Work Comp I <br /> T ICC Tedutician's Certification Number Eq—tion Date <br /> R ICC IrsmWS Certification NHmrber E�cation�lo <br /> Tank mI Tank Size Chemicals Stored Dale UST tislatled <br /> GuneadyJPrevioRsly <br /> T <br /> A <br /> Y <br /> K <br /> Lft, <br /> r.-JApPmved Lwpprowd wi�R conditions U6sapproved <br /> (See AMmhnntWith Condions) <br /> Reviewers Name - Date <br /> itlt4 P-ERFO,BN.AIL.NG7[M.¢+R.ALCIJ@O6�CE7�471isAN..Y]90ONQ�lB[IY.t �NICF -SiAlE1�IlNRS�Aen8ltE5 ACDREGCAAT GFSAN <br /> JOAOIAN CO(A".ONROWM ENTAL HEALTH tEPMRM3fT_0JNM OR LK'875®AGEN S SKMTtHE GERTFIFS THE WlO AI:,-'I CER71FY THAT IN <br /> THE PSWCRMANCECFTHE WOW FOR WHL^HTHS PSUUT tS SWEV I SWL NOTB67DY ANYPERWN W S)CHA UNCERASTO BECOW SALIB'f70 <br /> Y1K7RI�RS IKN LAWS OF CAUFOIRIA' OOWRACrWS HRRMOR SZIBOMMACING SK; &TL%RE CSZTFIE3 THE FOLLOWHG -1 CB?TFY <br /> THAT WTIECF <br /> THE FOR WHICH TEAS PHRMR IS ISSIID.I SHALL EMPLOYPEFWN5 St1B.ECfTO Y1GW%MS C0I03BSATION UIWS <br /> BIWNG RMATION: <br /> Indicate the responsible patty to be billed for additional EHD staff free expended beyond permit payment coverage per tank. If <br /> the panty des' dated below is ddferent than the pertnrt e.g. property owner, the party must adaRowledge this <br /> resp='T'il) the belting by signet and cafe below. <br /> NAME <br /> ADDRFSS <br /> SIGNATURE .Q <br /> ER23DO38(revised 119M) <br /> 1 <br />