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ENVIRONMENTAL EALTH Ei'ARTME�T - <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 />THS PSUCT E)nRFS 90 DAYS FROM THE APPROVAL DATE. INLNCATE PERMIT TYPEBELOW <br />UA <br />K RE IROFIT LIMPING REPAR/RErROFTT UID -C RE JUPJR--'TRCRT <br />F EPA Site # Project CantaVt & Telephone # <br />CFacility Mame ((t Phone # <br />L <br />Address <br />I Cross Street <br />T <br />y ownerloperator Phone 8 <br />C Contactar Name ` i``_ (�� Phone # <br />0 <br />TCont-acbr Address �) \ CA Lic # Class <br />A insurer ioi--Q—f V Work Comp # La (jC1 <br />TICC Technician's Certification Number Expiration Dat9 <br />R ICC Instaltet's Certific�fion Number 1 LL_ Expiraf 1} <br />Chemicals Sorted <br />Tank !D # Tank Size Cunenftyfilln iously L]a� UST Installed <br />T <br />A <br />Y <br />K <br />p LIApproved I.Approred with conditions UQsappr�ved <br />L (See/ Attachnent With Conditions) <br />A <br />N Plan Reviewers Name Dato <br />APPLICANT MUST PE ORK-ALL M0RK- LAL .Y] aM CX7[R [TY _Q1 Z ES AND _G2��ULAT30NS_ OF SAN <br />JOACKAN COUNTY, ETJVU?(X JTAL WAL..TH 09-ARTMENT_ MNK R OR LMSED AGEIC-S SIGNULIRE CBMFES THE: F OLUVA43 11 CSTFIF ' THAT IN <br />THE PERFORMANCE OF TI - E VVOW FCR VVHI THIS PE RMf 1 1S ISSUED, I S1- L NOr EMPLOY ANY P&cS3 ti IN Simi A UAFS� ASTO BECOME S: te=-if T O <br />WORK19tS C *PE�TKri LAWS OF CALIFGRNUt" CONTRACTC5rS HIRING OR SK NATURE CBTIRIES THE POLLOM4G� '1 CERTIFY <br />THAT N THE P=- ZFORMANCE OF THE VV,)FM FOR WHIQ-I THIS PERUFT IS ISSUE], I SHALL EMPLOY PERSONS SSJ3-ECT TO VIDrRCrR'S CJiG t}5ATM MAKS <br />CF CAU/l' <br />BIUJNG INFORMATION: <br />Indicate the responsible party to be billed for additional BID staff fcne expended beyond permit payment coverage per tank_ If <br />the party designated below is different than the permit applicant, e.g. property owner, the .party must acknowledge this <br />resnsibifity for the billing by s rmah+re <br />wand dam below. <br />wtF �4�1� �� �_��1 Y�171TI� s.-='� �„� CS--��l=�ril3�ft ac� <br />Z <br />