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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Tkird 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 PERMIT EXPIRE890DAYS FROM THE APPROVAL GATE- INDICATE PERMITTYPE 8FLOV,1: <br /> ANK RETROFIT [1F;PMrjtEPA1R/RETROFrr a=REPAWIREIROFIT .. <br /> F EPA Site# Pruject Contact&Telephone# <br /> � FacildyNanv Qp xrnt Acid 7(p Phone* q) yvg-P5V'& <br /> Adcres9 <br /> Ir Goss Street F 61 Cl �_I z �c <br /> Y Owner/operator N d tS`, f A_A e.L Phone 4-A0 <br /> o ContradarHarne l' o '7') r CGS C 7e# or7 $yS-gSg(p <br /> N Contractor _ F3 3_20 b <br /> T 5 ra CA l.ic M class <br /> Insurer IV14 <br /> C E WIr w«ttc«r,p <br /> cICC Technician's Certification Number umer Jia 6 /—& 1" Expiration Dale F/.- <br /> 4 /9 <br /> R <br /> ICC Installer's Certification Number rj L S-P ✓`vu u r- Expiration Date <br /> Tank ICM Tank Size Chemicals Stored Date UST lnstalted <br /> C urrently/Previousty <br /> T _4.2 19,000 I Ga~soi;n� I q9Z <br /> A `i lt) 'a allan GO�s�1 i n z T 9 9 2 <br /> N /r� <br /> K 1fJ bi)D (Q, <br /> P ClApp edproved with conditions ODisappmved <br /> L ( Attachment WO Conditions) <br /> ' N Plan Reviewers Name I L' Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN (N COUNTY ORDINANCES.STATE LAVAS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUN COUNTY_ENVIRONMENTAL HEALTH DEPARTMENT.OVW ER OR 10ENSED AGENT'S SCNATURE CERTIFIES THE FOLLOWING 9 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR V"CFI TI-IS PER MIT 1 S ISSUED.I SHALL NOT EMPLOY ANY PERSCN IN SUCH A MANNER AS TC BECMAE SUBJECT TO <br /> WORKEitS CONPENSAnON LAWS OF CALIFORNIA' CONTRACTORS HIRING OR SU8CONTRAC7NG SIGNATURE CERTIFIES THE FOLLOWING: 'I CEa7TIFY <br /> THAT W THE PERFCRMA OF THE WORK FOR VMCH THIS PERNIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFDRNIA.' <br /> ApPa SI oetue' `L LC%Ll L L L,,, Dale <br /> � 3 �? G <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time eKpended beyond permit payment coverage per tank. It <br /> the party designated below is different than the permit applicant; e.g. property owner, the party must acknowledge this <br /> responsibility for the biting by signature and dale below. /( /J oft t' 10 -q2cl <br /> NAME �4: TITLE !1 /y PHONE t OO o <br /> ADDRESS 1951n1?S Px4trsor 94.S5 "aA -"ra <br /> SIGNATURE ( 'J <br /> EH23003a(revised eraM) <br /> 1 <br />