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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 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW <br />UTANK RETROFIT UPIPING REPAwREiRORT U= REPAIRIRETRORT <br />F <br />EPA Site # <br />Pmject C ntact & Telepharre # <br />A <br />G <br />Facility Name K °j <br />a, I, <br />Phone # ©' <br />L <br />Address l <br />'L A <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator '� S <br />t <br />Phone # <br />o <br />Contractor Name <br />Phone # _ q44 <br />T <br />Contractor Address r <br />(tee J: e ` c', V- - CA tjc # (r b cL 7(p Class f }� jj , f_.0/? <br />A <br />Insurer. is Ty <br />Work Comp # �C3C�U % �% <br />T <br />T <br />ICC Technician's Cergmuttion Number <br />Expiration Dabs <br />o <br />R <br />tifiICC Installer's Certification Nurnber <br />Expiration Date <br />Tank ID # <br />Tank Size Cunenntlry/Ptev Stored <br />Dane UST Installed <br />T <br />A <br />W <br />K <br />P <br />UApprovedproved <br />Dismved <br />with conditions Uapp <br />L <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name �MI-.J <br />1 .� Date R. <br />APPAICAFrT <br />MUST PE2FCR-[.ALL1NORKKA <br />ANURLA ASDA�4TK7Ats;(JFISPN <br />.tAdTHSANJCaACyMC=ETY. .STATE4W; _REGl <br />JOAGM C=47Y, EW RONBul 34TAL HEALTH OFFARTMENCT, CINNIER OR LMSED AGB4M SIGNATURE CEIMFIES THE FOLLCVA437 "I CERTIFY THAT IN <br />THE PERFORMANCE OF TI -IE WOW C FCR V"CH THIS <br />PERMIT IS 1SSLIED, 19- 1- NOT EMPLOY ANY PERSON IN 9" A MANNER ASTO BECOME SLIR ECT TO <br />WORKUrS COMPENSATION LAWS OF CAUFCF2 W <br />CONTRACTOR'S MING OR SLEOONTRACiM SIGNATURE CERTIFIES THE TaOLLONIO 1a 9 CERTIFY <br />THAT IN THE PERF OF THE VV, -W FOR Y1MIQi THIS PERMIT IS SSLED I SHALL EMPLOY P6;tSC)NS SUB.ECT TO ACWERS COMPENSATION LAWS <br />CF CALIFORNIA` <br />BIWNG INFORMATION: <br />Indicate the responsible party to be billed for additional EHO 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 anis <br />responsibility for the baring by signature and date below. <br />NAME SU` L'• EC..t.-!!) G( TITLE%(Jt',=r Cave ]' i;) PHONE <br />SIGNA <br />EH23DO38 (revised 8MM) <br />Z <br />