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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 469-3420 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 RETRORT UPIPING REPM RETROFIT 4 U6Dc REPmuRETRoRT <br />F <br />EPA Site # <br />PmjectQntact & Telephone # -3 -3 9 <br />C <br />Facility Name <br />Phone #OV <br />LAddress <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # <br />Contractor <br />Phone # <br />0 <br />N <br />T <br />Contra r ss <br />CA Lic # <br />R <br />A <br />Insurer <br />Work Comp # <br />C <br />T <br />ICC Technician's Certification Number <br />Expiration Dabs <br />0 <br />R <br />ICC Installer's Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />ChemSla <br />We UST Installed <br />Curiently/Pr rely <br />T <br />A <br />W <br />K <br />Pp <br />ved <br />roved with conditions UDisappr�ved <br />L <br />A <br />L <br />( Attacierlent With Conditions) <br />N <br />Plan Reviewers Name <br />Date <br />APPLCAt <br />MLiST PEFOM-AL M"K KA <br />.YiJaMIMCCUUY. ..�AiEAAL, PEa lFS. AB_R9%AAOOF SAN <br />JOAQUN COUNTY, EVIRONMENTAL HEALTH DEPARTMENTOWER CR LK�tSD AGENTS SKMTURE CERTIFIES THE FOLLCVA?U: 'I CERTIFY THAT IN <br />THE PERFORMANCE <br />OF THE WORK FOR V"CH THIS PERMIT' IS ISS, t SHALL NOT EMPLOY ANY PERSON IN SUCH! A MANNER AS TO BECOME SUBJECT TO <br />VYORICERS <br />COAIPENSA CALIFORNIA.- OF CALIFORN' CONTRACTORS HIRING OR SKyNATURE CERTIFIES THE FOLLOM4G `I CERTIFY <br />THAT IN THE PERF THE WORK FOR <br />Kil THIS PERMIT IS {SStlt�, I SHALL EMPLOY PERSONS SUB ECT TO WORKERS COMPENSATION LAWS <br />CF CAIJFORWA.- ' <br />AppficartsSi9r8hre <br />BIWNGUNFORMATiON: U - -I <br />indicateponsible party to be billed for additional EHiD staff fine expended beyond permit payment coverage per tank_ if <br />the party e . noted below is different ttsan the peimd applicant, e.g. property owner, the party must acknowledge this <br />respon ity r the WINfx� b/y1/slig�natu )y and date below_ ® A 1 <br />r <br />EH230038 (revised 8/8/06) <br />1 <br />V14Z <br />