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I F <br />A <br />C <br />I <br />L <br />1 <br />T <br />Y <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />EAiVfROl�14NE�t AL—H—EA1M H DtPARTM <br />ENS <br />SAN JOAQUIN COUNTY <br />344 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3410 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />P!S PERIE 'Xr IRES 90 DAYS FROM THE APR2oNAL I)ATE INDICATE PERMfr TYPE BELOW <br />UTANK RFMOFTr UP <br />EPA Site # <br />Fool Name <br />Address <br />Cross Street <br />0-ner/Operator. <br />Contractor Name <br />in <br />Contracr Address <br />Insurer // <br />r <br />ICC Technician's Certification Number <br />ICC Irtsti;liWs Certification Number - <br />P <br />L <br />A <br />N Plan Reviewers <br />Tank ID # <br />IPING REPA[RIRETROFTT LJUDC REPAUVREMDRT <br />PFeject Contact & Teleohorw # I IE -i <br />6( r Phone # <br />Tank size <br />Phone # <br />Phone # <br />CA L.ic # 7 <br />Work Comp # <br />Expiration Data <br />Expiration Date <br />Chemicals Stored <br />Currently/Previously <br />maCl <br />-c--16-PL 5043/k -t <br />nage UST Irtstaed <br />UApproved Lkpprnved wish conditions <br />approved <br />------ % (See Attachrrent W&I Conditions) <br />Data 6L ✓i� <br />I APPLICANT t<LLLST PERFORM ALL 1Arj4C NLA[ ICCUZO r^c tArt� <br />Yq4CLSQItX]Ci�rtyO�ntrtewrcc,SSAIEI/1M45:At�Q_RL6SAtD.RF7`tl� e <br />.IO;4(iJlN COUNTY, ENI/IROt�.t7AL HEgt.TH O=P,gRTiJg•JT. GM•782 OR - - - — --- - T�°S..;CF SAN <br />LMS AGBa S SCNATURE CSrF FICS THE FO LOVA: 'I C SVIFY. THAT IN <br />THE PERS Cot VCE OF THE WOW FM AlWHICH 7i CS PERW IS Mia) I SHALL NOT F 1p' ANY PERSON IN Sk)CH A MANMR AS TO FAME SU31�T TO <br />YK7i2fCE3R5 COAQ'Ef LSATKN LAWS OF CALL( RAL, FIRING OR SM � SUATURE MMFIES THE FiX� '1 CERTIFY <br />THAT N THE PERF OF THE VVCW FOR V"C I TFaS PERMrr tS tSSI,®, 1 SHALL EMPLOY <br />CF CALFUWA.' J PERSONS SU3 EGT TO VVOfilCEIZS CATION LAWS <br />Ae <br />BILLING INFORMATION: <br />indicate the responsible party to be billed for additional EHD staff tine a nded beyond <br />the party designated below is different than the g. y permit Payment coverage per tank_ tf <br />msPonsib Ity the bite �`rr'd a 9• property owner. the party must ackrwwledge this <br />ng by signature and date below_ /� �J� ,( <br />4AME //` GK_ ME `" ' , CLQ /r l �`I C( PHONE # `l O (E� � 3/ <br />1D ESS <br />LLj�V1 E <br />IGNATURE /� , <br />EHt230038 (revised t3l8/06) <br />1 <br />