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0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQU N 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 />EPA Site IF <br />THIS PERYfTEKPIRFS W DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELCW <br />UTANK REIROFTT UPIPING REPARIRETROFIT L_6DC REPAIR/RETROHT <br />Project Contact & Teleohone i <br />A <br />Facgily Name <br />Phone i lJ <br />I <br />L <br />./ nn <br />Address �Je� f <br />eQrlua <br />t <br />Cross Street <br />T <br />Y <br />Owner) Iperator r : I <br />Phone i <br />oContactor <br />Name <br />Phone! _ !3/�3 <br />T Contracts <br />Address b <br />Class e -%U <br />CALX# 4+C:�'n7(o G 1-' <br />A <br />Illsuter <br />work comp i G5D ey- <br />T <br />ICC Tedvtician's Cenification Number <br />Fspeafion QatB <br />O <br />R <br />ICC InstaWs Certification Number <br />Expiation Date <br />Tank ID i <br />Tank Size <br />Ch Shred <br />Date UST Installed <br />Curmntly/Prevlomly <br />T <br />A <br />u <br />K <br />PFRevie�ww, <br />ppmved <br />improved torah yrs UD=RXDved <br />L_i� <br />WN11tl Co�ihOtD <br />Y <br />Data <br />nPPixatu u5isr r�RraaY.N1 tvactK¢tAocotmancEmDisw <br />J ILANPBR QOIAJTY, N1 : @ <br />oeO retrr�ta[rY.mro ,.. r� <br />Q4TH2 OR L 3TFIE ATHE FOELOWNG- .G_cCEFMFS;OFSIIN <br />C8 7 N <br />A(8II5 SIGMY <br />THE FER <br />-E <br />TRE PERFORMANCE <br />IT. <br />OF TH <br />OF THE WaR1C FCRMlRLFI THIS PERMIT <br />W F RW-ALTHW41C TM PE <br />SY ECT <br />4AL NO PER <br />6 tSA�,19-WL K7TEMTiDY ANY PERSON N SUCH A YAL@H2 ASTO BE�MESI$IECrTD <br />SUFIS ASTO <br />BECOME <br />VYOWERS OOWENSATKN CANS OF CALIFURNIA.' CONTRACTORS <br />HDiINGOR SUBOONTRACING SKMTURE CERTIFIES THE WLLOWRIG 'I CERTIFY <br />THAT IN THE PEtFOR OF THE NORI( FOR VWHIQR THIS PERMIT IS Lq%M. I SNALL EFLOY %SX-CrTO VKXWJgiS COMPENSATION LAWS <br />OF CALIFORNIA.' <br />Af4kadz2p22!e <br />BIWNG INFiBfTMATIM, <br />Indicate the responsible party to be billed for additional ERD staff tine expended beyond permit payment coverage per tank It <br />the party designated below is different than the pernit appfimnL e.g. property owner, the party most adsowleRge this <br />responsib fno�r the billing by signaturenand date below. <br />NAME \ it'JU f I C- I ,, f A TITLE `� W f / / ' l i%Clr1/1 PHONE i l `C �� Y <br />EW3DO38 (revised MM) <br />im <br />