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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 EXPIRES 90 DAY .. <br /> UIS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW. <br /> TANK RETROFlT LIPIPWG REPAWRETRORT UUDC REPAPJRETRORT <br /> F EPA Si>s# ProjectCantact&Telephone# - C <br /> A <br /> C rAdcdfmss <br /> ity Name i Phone# - r <br /> - (� <br /> I s Street <br /> T <br /> �' erlOperator - Phone# 1 C <br /> 0o Contractor Name 1 <br /> Phone# 2(,q ! <br /> N Contracbr Address R CA L"# - . <br /> T <br /> A <br /> Insurer work Comp# �' ) <br /> TICC Technician's Certification Numberc (� Expiration Data - <br /> R ICC Ir►staller's Certification Number Expiration Data <br /> Tank ID# Tank Size Chemicals Stored Dale UST Installed <br /> Currently/Previously <br /> T <br /> A <br /> u <br /> K <br /> P UAppraved {\]Approved with Conditions UDisapproved <br /> L (See Attachment Wdh Conditions) <br /> A <br /> N Plan Reviewers Name Data <br /> APPLICANT MUST PERFCR.M ALL WRK NACCOMANCEMYrTH_SAN J09Cy M C.OLZITY ORM I�,STATE LANG AMU Fal AW REG[AATMS CF SAN <br /> ECALIFMZ <br /> AYTY,EW RONMENTAL HEALTH DPARTMENT.OIVNEI2 OR LX&tSED AGBV'S SIGNATURE CE2TIRES THE FOLLOV'JM: 'I CERTIFY THAT IN <br /> ANCE OF THE V"?K FCR WHC;H THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME aRIECr TO <br /> OMPIENSATC]N L AV.S OF CALIFORMLIL' CONTRACTORS HRMOR SICrNATURE CERTIFIES THE RXLOWNNG 'I CERTIFY <br /> PE2FOR#AAICE OF THE WOW W FOR MKIA THLS PERMIT 6 ISSUB),I SHALL EMPLOY PERSONS SUBJECT TO VY W.B;rS COMPENSATION LAWS <br /> A-' Cr'r 1 Tale 1 ; <br /> D. E L�, <br /> BIWNG IN RMATION: <br /> Indicate the responsible party to be billed for additional EHD 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 must acknowledge this <br /> responsibility for the billing by signature and date below- <br /> NAME f C. 1 C C- �C<i(''�L�l j nT>E_�1 P ,3 i2; r� �iV•� ' PHONE# 269 :IS I -t 0 557 <br /> ADDRESS <br /> SIGNATURE �� I <br /> EH23DO38(revised affl i) <br /> 1 <br />