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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN 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 E)"RES 90 QAYS FROM THE APPROVAL DLATE LR�_^ICATE PERMIT TYPE BELOW <br /> UTANK RETROFIT UPLPiMG REPARmEmo TT UjDc REPAIRIRETRORT <br /> F EPA Site# Project Cantact&Teleofwne# - <br /> A <br /> Facility Name — Phone# <br /> L Address 1 <br /> I Cross Street <br /> T <br /> y OwnedOperator CRANDH&O Phone# — 3 <br /> < <. <br /> Do Contracdar Name Phone# i <br /> N Contractor Address2finft�o CA Li-# Class <br /> T <br /> A (usurer rrc Work Comp# 1 11O <br /> TICC Tedd ician's Certification Number Expiration Dais ` <br /> R ICC lnstalWs Certification Number Expiration Dats <br /> Tank 1D# Tank Size Chemicals Stared _ _----tale UST Installed <br /> Currently/prevrously T <br /> T <br /> A <br /> u <br /> K i <br /> PLIAppmved Opproved with conditions LJDsapproved <br /> L (See A tachrrent With Conditions) <br /> A <br /> N <br /> rPl.anRevie.vA-am Name /� Datta <br /> APpttcArtl'uttsrF.�c�rc u�.Wt�lCt�i.ao�anc�sert7risAN.oma,�allxx.tacrY.orzzucaaerc��..�IE�,aysi,,aeu��ta�s.neo.� TioarsoFsat; <br /> JC ACL kN COUNTY,E WIROWENlTA,L HEALTH C13:0 TNEATT.OWER OR LJ aSE D AGBC S SKNATLR3E CSTI]FES THE F 0L.LOYRru 'I CERTIFY THAT IN <br /> THE PBUT RI LANCE OF THE WCC FCR VWIK;H THIS PERMIT IS=JED I SHALL WrSE OY ANY POr SM IN ax 4 A MAN E3R AS TO BEC ME-%EJ =T TC <br /> WORKERS COIIPeZSATXN LAWS OF CAL1FCFdW OONTRACTLFZS HIRW OR SUBCCNTRACTM SIGNATURE CERTIFIES THE FCLLOWrJG7 1 CERTIFY <br /> THAT IN T1-IE-FS?FGR4rrNVCE CF THE WORK FOR W-Wl-i THUS PSZNIT tS LiStM,I SFIALL EMR-0Y PANS SU3ECr TO WyC) EfZS OOMPeJ TtJN LAWS <br /> CF CALLA' <br /> Amts S41ad re Title Date <br /> BIWNG INFORMATION: <br /> Indicate the responsible party to be billed for additional B-iD staff tine 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 mast admowkdge this <br /> responsibility for the bang by signature and date below_ <br /> NAND �1m V.�1 \1�J TS"��rl-1JIC�.JI-Y 11L4 I l VCJ P`!n4lc�' LJ.J� -TCU l-(� 1 <br /> ADDR>s5 e-9� <br /> SIGNATURE <br /> EH23DO38(revised BW06) <br />