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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 /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW <br /> UU <br /> TANK RETROFIT PIPING REPAIRIRETROFIT 1-6)C REPAIR/RETRORT <br /> F EPA Sim# Ptejed Contact K Telephone# <br /> A <br /> C Facility Name �Lk3lcaC Phone — �75 <br /> I Address `t 2l 0-9 , 2 . <br /> I Cross Street <br /> T <br /> Y Ovvner/Operafnr V Phone# _ <br /> Co Contractor Name ts Phone# _ <br /> N Contractor Address Loemft- �FaYc# Class l4Z <br /> R (usurer <br /> A K P work Comp Ix P rjpp3 i�'�-O 1 <br /> TICC Technician's Certification Number Expiation Date <br /> RICC kv4aws Certification Number Expiration Data <br /> Tank ID# Tank Size Chemicals Stored <br /> Cunentty/Previously Date UST Instal3ed <br /> T <br /> A <br /> u <br /> K <br /> P L.Approved *Proved with conditions UDisappmved <br /> L (See�t chrwnt%mm Conditions) <br /> A7^� <br /> N Plan Reviewers Name - X <br /> APP13C1�ArI►tllS7 FEI�OBJtt.11I1 VK7R1C L�LAOCt flA�► SA4T1i SAN.Y�AO1MfX]lRitY Q tEtAa1C S. SAIF LJUII4S/1�[3 SLR. S AND RE%hATK7NS OF SAN <br /> "C M CXXR Y,ENVE"A�ftAL HEALTH DEPARTMBri.OWNER OR LtCBd,SED AGENT'S SIGW�TLXZE CERTIFIES THE FCLLOVA<;- 'I C,E RTIFY THAT IN <br /> THE PERFC [ANCE OF THE WUW FOR WI-ICH THIS PERMtlT IS ISSUE,I SWILL NOT EMPLOY ANY PERSCM IN SLCH A MANNER AS TO 8EMME&JEU=TO <br /> W OF00;rS CO PENSAnQd LAWS OF CALFORNIA' CC*Jn ACr0R!S 14RM OR SUBCONTPACT24G SX3NATURE CERTIFIES THE FOL LOWING 'I CERTIFY <br /> THAT N THE PERFORMANCE OF THE WORK FOR MCIA THIS PERMIT IS MED.I SHALL EMPLOY PETMCM SUB.ECT TO WORKERS COMPENSATION LAWS <br /> CF CJIUFORNtA' Q <br /> AW5..ts Sig�lue jb Y I 1 1 V�MI J Tdie Dale _ l) I I <br /> BILLING INFORMATION: <br /> indicate the responsible party to be billed for additional EHD staff fine expended beyond permit payment coverage per tank If <br /> the party designated below is ddierent than the permit applicant, e.g. property owner, the party must acbwwtedge this <br /> responsibility for the billing by signature and date below. <br /> NAME N\ nnE 6 zjCf-f Lff X <br /> ADDRESS ��� 1�lAILLLY ��UVT���n V� t 1 LSJ <br /> SIGNATURE=' Q <br /> EH230038(revised BMM) <br /> 1 <br />