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ENVIRONMENTAL HEALTH. EPAR ENT <br /> J. -SAN J®AQU1N 00UNTY ` ECLIVEL) <br /> 600`.East Main Street; Stockton, California 95202 V L3' <br /> Telephone (209)468-3420 Fa.x,_(209)468-3433 MAR' s 2015 <br /> APPLICATION-FOR UNDERGROUND STORAGEco <br /> T/XI Hr V' <br /> RETRC3FIT OR"I?IPIWG REPAIR`PERMIT IT ,RONM N <br /> Y5 FROM THEAPPROVAL DATE WDICATE PERMITTYPE BELQW:' <br /> OTANK:RETROW'11 PIPING.R.EPAIkA ETROFIT ❑UDC REPAIR/RETROFlT 0 COLD STARTIEVR UPGRADE <br /> Phone aq c �- <br /> -Address - <br /> Gross Street <br /> Owner/Operator I Phone# <br /> G ContractorName \ • , Phone# i- . . <br /> Contract orAddiess ,JT(Y:KYSr1,CA.S'rwl2lfJ CA LIC#(YaW- P Class <br /> Insurer.tMaltv 1TVIL Work Comp#- (j Vq 6 <br /> T ICC TechMdan's Name Expiration Date <br /> D -ICC.Instaflers-Name - -- F-Vlration Date <br /> Tank system work area Tank Size - Chemicals Stored Currently Date UST <br /> t�sTIW�Bau^P.o11mk0ierW.WC VL ) Installed <br /> Appm .. Approved with conditions ❑Disapproved <br /> --- --- --( itactuneTirWitli"CGntlitidns) _._._._. ..11r�lI .._ --------- <br /> erme <br /> Plan Reviews NaD <br /> .APPLICANT MUST PERFORM ALL'WORK IN ACCORDANCE WITH SAN JOAQUIN COUTY <br /> ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAOUK GOUNTY ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE„FQLLOWINQ:_:I CERTIFY THAT IN. <br /> THE PERFORAIAFJCEOF THE:WDRIC'FOft WHIOITIrfI5PH2MIT75'IssUED ISHA4'NOT EMPLQYANY PBWNJ_N34CH A.MANNEILASTOBEGOMESUBJEaTTI]. <br /> WORKERS'C(M7PENSATIOA LA4Y�OF'CALIEdRNTA CONiFtACIORS HIRWG OFi SU9CONR7ACnNG SIGNATURE CERTIFIES TfiE FOLLQWWG '1 CERTIFY <br /> TNATlt�rTHEFERFORMANGE'aF7HE WORKFQR}NFIICH T}iISPEtRMrr LS SSIi.F,g 1b]WI1 EMI'1:97CP SDN Syj6JECT 7D.WQt3.1...... K4?EN$A11QN.V.jVL$:, <br /> sSlgAanne (:`• TMe 1 . oats ' <br /> -. -..-- '— -1411LINGINFORMATION:_... ... .. <br /> -----l/lICafO.lhe-leSpOnSlae pH 112dfOFad�Ef fleRal�f'iD5t2ff-(1iTig”" „ B .bQY(' -..pgnfUt.QayuJSflt_f3WS�flga.per Y2nk If _.-_. <br /> _ 'Ra[iY 9Da fiel rerlt_thaa tFi`e--PAIL aPP11caM: e.g. pmp&,tY-owner-the PaMY-mRmt-acknowledge this -...... _ ... <br /> . .-resop nsibiifiLfor the bdling_by.sWrIature and date below.. - <br /> NAME [�liYT llf�llIrej '� PL'�Y�... .. TRLE—�ICJRC (YRZIVC, PHONE# - C -0� <br /> SIGNATURE It4tcLiuvulkl DATE :3-12--r <br /> f )— <br /> EH2so0sa(wisedoW7ni)., ._..: . : . <br /> - 2 <br />