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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 /> THUS PERMIT E)(IREs 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW <br /> UTANK RETROFIT UPIPING REPAR/RETROFIT DC RFpAIP F0ROFIT <br /> F EPA Site# Project Cmtact&Telephone# 3 <br /> A Facility Name / # , <br /> L Address 1A r a' <br /> I t <br /> Street <br /> T <br /> Y /Operator Phone# <br /> C ctor Name /�C'. Phone# 's <br /> N ctor CA lac# ) GassTR lQ Work Comp# � f6 0 <br /> A <br /> C <br /> ICC Technician's Certification Number p'Z —CL T Expiration Data Q <br /> T <br /> RICC InstaWs Certification Number E> afion Data <br /> Tank Size Chemicals Stored Dale UST Inst Aed <br /> Tank ID# Currently/Previously <br /> T <br /> A <br /> M <br /> K <br /> P lJAppraved with conditions UDtsaPPro� <br /> L ()�pmv� <br /> With Conditions) <br /> A <br /> N Pian Reviewers Name Data <br /> APF?l1CANT MUST LST P[RFCRIt A11 ShiL7F2tC PL 4C 1 WITH SAN JOAaJN CaJNTY OE E S.STATE LAWS.AND RLLES AND f2EY'"TMS OF SME <br /> .)OACUIN COUNTY,EWIR0Nh E3NTAL HEALTH DEPARTMENT.OWt'E2 OR L1CRISED AGENTS SK2,IATURE CE TTIFES THE FOLLO JW, 'i CERTIFY THAT W <br /> THE PERFORMANCE OF TIS WORK FOR V"CH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON W SUCH A MANfNER ASTO BECOME SUBJECT TO <br /> WORK R!S COMPETtSAT"LAWS OF CAL FCRN1a- CONTRACTOR'S HERW OR ajBCCNTRACTpr,SIC-NATURE cERTEFIES THE 40L10WH4G -I CERTIFY <br /> THAT IN THE PE2FCR",,N Lr THE WORK FOR THIS PERMIT IS OSI.®`SHALL EMPLOY P01-SOWS WI-ECT TO WORKERS COMPENSATION LAWS <br /> CF CALFORtIIA� / <br /> A,�ts Sigiehre T� <br /> BIWNG I MOTION: <br /> Indicate the responsible party to be billed for additional EHD staff tele expended beyond permit payment coverage per tank If <br /> thearty designated below is drtt'erent than the permit appficani, e.g. property owner, the party <br /> must �e this <br /> P <br /> i" f th b sig re and date below. <br /> PHONE# <br /> ADDRESS \ <br /> SIGNATURE <br /> EHt230038(revised MM) <br /> 1 <br />