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• ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN COUNTY <br /> 304 East Weber Avenue,ThW Floor,Stockton,California 95202 <br /> Telephone:(209)468-3410 Fax:(209)468-3433 - <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TtttS PERU1 TE*1RES 90 DAYS FR0U THEAPMWAL DL!TE INDICATE P—RW TYPE BE r—W <br /> DANKRETRORT LJpIPING REPAwRmoRT Lkw REF'AuuRETRaRT <br /> F EPA Site# Pt-jest Cantast&Telephone# Cl( <br /> A <br /> c FaciRy Name' Phone# �7 <br /> ' <br /> L Address A ► 7 <br /> TCross street <br /> yOwrrecNperalnr i Phone# <br /> D <br /> Confrador NameLaiTh Phone# 69 01 <br /> TConiracbr Aridness CA EIC 1K Class <br /> A Insurer work Comp# bo <br /> TICC Technician's CertificaWn Number Expiration Date <br /> R ICC Installer's Cerf mfion Number Expiration Date <br /> Chemicals Stored i2-Ii-USTJnstalled--- <br /> T <br /> A <br /> ra <br /> K <br /> P LIAPproved p..d Y1 M r As UC�is�proved <br /> L (SeeAttacdarent With Conddiorts) <br /> A f <br /> N Plan Reviewers Name Data <br /> 11 APPIKAMiML1ST gra_u air• fbl ACXR ANCE!Aff sa_w lXlC�+[IYt�OI_NAtLICJ ..SGRTE1AiN5-,A�iSiIL S.At� _ ALS:OFSAN <br /> JOACi M CMAIM,&WROME NrAL I�ALTH ARTYBJT OWN6t OR UX81SED AGENM SKMTURE CERTIFIES THE FOLLDVAG: R CEKT Y THAT IN <br /> THEPStFURMANCEOFTHEWOW FORV*MCH71• PSPAffrISBMW,ISKALLWT51FLDYANYPE WNINS)CHAUAN13 AS-F0WMUESJBJEETTD <br /> WORKERS COR#S8 SATICN-LMS OF CAt i:Ua OONI BA=R'S HIRING OR SUBDONTRACrM SM A7LIRE C ERMF ES THE FOLtOMY M 'I CEUIFY <br /> THAT-IN THER M E OF THE WOW FOR V"CH 7HrS P6U f RS ISSN I SHALL EWU)Y PMSONS SUS -Cr70 WOWERS C:3Y39XK)N LAWS <br /> GF CAL»:IIA.' ) <br /> APPE-rts _t__]Y i!_ b-)kkku Tdie " <br /> BIWNG t RMATION: <br /> Indicate the responsible party to be billed for additional END staff fine expended beyond permit payment coverage per tank If <br /> the patty desgnated below is Merest than the permit appCfcK e.g. property owner, the .party must acknowledge this <br /> responsib ty for the billing by sgnature and date'below. <br /> WME 1�1m 1�r1� TITi E i_fl.U1 C tJt r1C9 f l UCJ _ 1-03 "1 <br /> aD I ssLo�Q <br /> SIGNATURE <br /> EH23DMS(revised 81MOS) <br />