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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN COUNTY <br /> 304 East Weber Avenue,Tkird Floor,Stockton,California 95202 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGRQ U/ <br /> ES�1 ND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRDAYS FROM THE APPROVAL DATE BELOW <br /> PERMIT TYPE BELO <br /> UTANK RETROFIT /// UPIPING REPAIRMMOFIT UuDC REPAi OOT <br /> F EPA Site# Project c rdact K Telephone# <br /> A1- r'73 <br /> C Facility Name ! ^h �f Phone It t <br /> Address <br /> ICross Street <br /> T <br /> Y Owner/Operator Phone# <br /> oContractor Name .� '• Pho # �- <br /> N Contractor ss _ CA Li # Class 2 <br /> T <br /> AInsurer oft / Work Comp# 61& r77 <br /> C !CC Technician's Certification Number Expiration Date / - C <br /> T " <br /> RICC kistallefs Certification Number Expiration Data <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P UApproved �pproved with conditions UDisappmved <br /> L (See Attachment With Conditions) <br /> A <br /> /09� <br /> N Plan Reviewers Name Date �� <br /> APPLICANT DEIST PERFORM ALL MCM INLACCORDANX tolEMSA6t JQM1M CO k1TY ORDINANCES,.STATE LAM ANU fill Es AdD-REM ATOMS.cF SAN <br /> "QUIN COLWY,ENViRCNWENTAL HEALTH DEPARTMENT-OkMJER OR LMSED AGENTS SIGtNATURE CERTIFIES THE FOLLOV NG: -1 CERTIFY THAT IN <br /> THE PERFORIJUVJCE: WOW FOR WHICH THUS PERMIT tS ISSUED,I SHA1L NOT EMPLOY ANY PERSON IN SUCH A MANNER ASTO BECOME SLIBJECf TO <br /> VvK)R ER'S C.OA�9NSA LAMS OF CALIFORNIA' OONTRACTOR'S HIRING OR aw ,NTRAGTw,srNATURE CEZrwiES THE FouD a ja -1 CERTIFY <br /> THAT IN TIE F ERF OF THE VK7rRlC FOR VVHIC}l THIS PERMIT tS 1SSt� SHALL EMPLOY PERSONS SU8 EGT TO VNORlCERS COIfFErSATION LAWS <br /> OF CALIFOFRWA' <br /> A>�ft e &_Tft�_ J 1 <br /> BIWNG t RMATION: <br /> Indicate the responsible party to be billed for additional EHD staff tone expended beyond permit payment cwverage per tank- If <br /> the party d hated below is different than the pe=ii icant, a-g- property owner, the party must aclawwledje this <br /> responsibH' r the bring by signature and date below- ^ <br /> NAME TITL 6L ;fa PHONE# <br /> ADDRESS <br /> SIGNATURE <br /> EH23DO38(revised affiW) <br /> 1 <br />