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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 /> THIS PERMrr EXPIRES 90 DAYS FROM THE APPROVAL DATE, INDICATE PERMrr TYPE BELOW <br /> UTANK RETROFIT UPIPING REPAFrt MORT UUDC REPAIR/REIRORT <br /> F EPA Site Project Cantad&Telephone# <br /> A <br /> C FacOity Name Eft Fad Phone 0 "29 72 <br /> 1 Address <br /> L r <br /> t Cross Street l l� <br /> r <br /> Y Owrier/Operator Phone i <br /> Co Contractor Name Phone It <br /> N Contracmr Address y Lic S Class <br /> T <br /> R Insurer �1 'l <br /> A .. work Comp cJV I <br /> TICC Tedmiaan's Certification Number Expiration Date <br /> RICC Installer's Certification Number - Expiration Dato - <br /> Tank ID Tank Size Date UST Installed <br /> T <br /> A <br /> u <br /> K <br /> P '`A UApproved proved with conditions UDi approved <br /> AN k . � -(See nt With Conditions) <br /> Plan Reviewers Name <br /> APPLICANTYIJST PEWCIRM.ALL NORIC IN.ACCOGDAt,CE 74SRNJDACIINCOUNTY.ORDMIANCES,.STATELAME.AID._81AE5 ANDREGLIATK7iS(F SAN <br /> JOAOUN OMMTY.BA%"AIEdTAL HEALTH DEPARTMENT.CVA E R OR LKEUSED AGENT'S SGMTUFZE CERRFESTHE FCL1CW G: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORD FORVMiCH THIS PERMIT IS ISSI1®,i%iNL NOTEMF4 Crf ANY PERSON N SL1 AMANNER AS TO BECOME SALIECT TO <br /> vvaR ERs COAPENsATKN LAMS of cm-tra Lov oomnRAcrcFrS HRINSOR_%mpbNJRAcTm SGNATLIRE CERTIFIES THE FQIDWIVG 1 CERTIFY <br /> THAT N TIE FEW CF THE VK7PoC FOR WiIM THIS PERMFT 6 ISSLE,1%W-L EMPLOY PHLSONS 5MEGT TO MCWnZS COIL E TIN LAWS <br /> CF CALIFORNIA' <br /> AppLcmG Si9cv4+e Tele <br /> BfWNG RMATION: <br /> Indicate the responsible party to be billed for additional EHD staff fine expended beyond permit payment coverage per tank If <br /> the party designated below is ddferent than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibd- for the billing by signature and date below. {'�n n -T <br /> NAME na 1 I L i U I `e r I TLE f I'I l'C� PHONE 0 2 140 / �,Y] <br /> ADDRESSsfp J <br /> SIGNATURE <br /> EH23DO38(revised&MM) <br /> 1 <br />