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Apr 28 10 07:03a Covey Engineering 8667068265 p.1 <br /> 09/09/2009 W-2D 11:o2 PAIL 2094883433 BSC EED --- Stockton Sazv Sta E4 DO <br /> �oo3lDDe <br /> t4�" <br /> ENVIRONMENTAL HEALTH DEPARTMENT " <br /> SAN JOAQUIN COUNTY APR 2 7 2010 <br /> 600 Fsi t Main Street,Stockton,CaitCornia 95202 SAN dOkQU'N COUNTY <br /> Telephone:(-109)468-3420 Taz:(209)4693433 s,^^r ," .':ibTAL <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT"MENT <br /> TKn PERM[TeWREa iso OAYS pyDL 7WxE AROVALDATC IFtcZ"�OFIMF[ICN D STAItTlE1lit BPGRAOE <br /> I]TANK RETROFIT ElPIPING RET"AIRIRETROFrr Q 060 REPAIRMS Eos »$ <br /> G EPA Site <br /> A p Project Contact a Talephonn# <br /> PIDRe# - bb 82 <br /> D Fadiy Name <br /> t <br /> L Addrees <br /> T Cross Street PITOMI <br /> Y Owner ra Phone ii z4q— ((o <br /> o COnttactor Name T CA Ucit o Clas <br /> N ContradorAddreSS <br /> T work camp <br /> R Insaer <br /> A ExWlalion Dale <br /> G <br /> ICC Tedintoan's Name <br /> r Expiraton Date <br /> R ICC IrlStaller'S Nafne pita UST <br /> Tank system work area Tank Sure Chemicals Stored Cwrar* trlstelled <br /> (lu.p,�pyrmA,at W.keerclwrec 1rz,�I <br /> T <br /> A <br /> N <br /> K <br /> I <br /> ? ❑ Approved <br /> ❑ APPMV04 with condldons LJDisapproved <br /> L (Sew AUachment WIFh COrdNans) <br /> A Dale <br /> N Plan Reviewers NeMQ� <br /> APPLICANT IIl1ST 7ERFORM ALL Y.'CPK IN ACOORDANCE WrTH SAN X AD WV O"TV OpplWtC68,STATE LAWS.AND RULF4 AND ReGULATIONa OF SAN <br /> —INSEOAJOALWN COUNTV,ENdIRON1IENTAL HEALTH TF�AS PERN6717 £S11E0. SHAIA.NOT 5MPLWIANT TPERSONINsuCH A MANNER AS O E130NE SUa=y <br /> THE PERFDRA%PAR- OFT LAWS OF 'l.l TOR'9HIRING GRSUaCONTR.X•TING St"11jRE CER7IFIE3 THe PCLLOWNSG-i CER1FV <br /> TO WORKERS COM WOR FOR WHICH THIS P s ISSUED.] <br /> SNPLL EHPLDy PERSONS dtiBJECT YO WORKERS COMPENSATION W W9 <br /> THAT IN THE POW I <br /> OF OALIFDANIe <br /> IT ' — <br /> A sslsnLNr. BILLING IN RMATION: <br /> party to be billed for addllbnal EHD staH Ilme OxPended beyond permit paytran1 Odadmowledge This <br /> varagr per tank H <br /> I" Party designated below <br /> different than tha permit aopilcant, e.g. Property owner, awe party must <br /> Indir�te the responsible <br /> responsiWi ty for the bllllno by Gtgnature and data WOW <br /> TILE M1244 IdG cS? _ F'NONB <br /> NAME — <br /> ADDRJ(taviftdO <br /> CITE OSKiN --�—'EHZ3 <br /> 1 <br />