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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 />THZ PERMrT E*'IRES 90 DAYS FROM THE APPROVA! DAT;_ INDICATE PatL-sIT TY_' BELOW <br />UTANK RLTrtDgT UPIPING REPAIIU MORT UDC RE AIR/RETRORT <br />F EPA Sit: # Prejed Cantact & Telephone #bj /- <br />A <br />c Facility Name - 1 Phone # f <br />Address c <br />I Cross Street <br />T <br />y Cnwner/Operator c RANWAINAPhone # - `� <br />oContractor Name Phone # <br />N ContracbrAddress <br />T CA tic # Cha s <br />R <br />insurer Work <br />Comp # <br />T ICC Tech <br />rlican's Certification Number Expiration Data <br />D ICC kts'aw. Certification Number Expiration Date <br />R <br />I Tank ID # Tank SizeI Chemicals Stored Date (1ST Instalk d <br />Canentiy/Previoesiy <br />T <br />A <br />H <br />K <br />P LlApProved AVVlApproved with conditions UDisappmved <br />L ($ee Aftactinient With Conditions) <br />A NPlan Reviewers Name (��' Date � -�& �y <br />APPLI AtZ YLLST P RFM%LALL VADMC DCA AbICE DISAN-KMaMCOLZLTY.05C1 ALICE5;. 1_W.ES !AN F ABD.FL~r i:E/1Tr.O SCF &M <br />"a -AN COUNTY. BWRONMENTAL FEALTH OS�A�8 OIMER OR LXa!SED AGEN17S SIGUknRE CERTIFIES THE FOL.LOvAK;- 'I CSTI Y THAT IN <br />TFE PBW:C AANCE OF TFE WOW FOR Mditvli MW PERW IS MJED I SriALL NOT EWUN ANY PERSC N W aCH A MANNER AS TO BED:)A[E 5 'T TO <br />LNOi3CE3?S COAG 5B TION LAWS OF CALIFCWk" CON RACTOFM MW OR SLJBOONTPA� SIGNATURE CERTIFIES THE FOLLOV&43- 9 CERTFY <br />THAT M THE PSRFORAlAM Z CF THE VCW FOR W -11C i THIS PFt1QT LS LSSLM, I SHALL EMPLOY PERSONS GU Cr TO AGWERtS Cold NNSATION LAMS <br />CF CALLFORMA.' <br />SIWNG INFORMATION. <br />Indicate the responsible party to be billed for additional ERD staff fine expended beyond permit payment coverage per tank If <br />the party designated be{ow is different than the permit applicant, e.g. property owner, the party must aclawwiedge this <br />responsbilrty for the bdGng by signature and date below_ <br />NAME l�,�m �i�� Tm =� <br />AMRESS (0N'a(1LYt)-r-,i n(-. <br />SIGMA <br />EH23DO38 (revised W&%) <br />0 <br />)�w <br />