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r� <br />L <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIlN COUNTY <br />304 East Weber Avenue, Third 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 />TMS PERMIT Exp RES so DAYS FROM THE APPROVAL DATE NDICATE PEERUfr TYPE BELOW <br />i I_... .. , "t i iasaau-'T?;:PMMrTRORT / 1 U = REPAIR/ nwRT <br />BIWNG INFORMATION-. <br />indicate the responsible party to be billed for additional EiD staff fine expended beyond permit payment coverage per tank- If <br />the party designated betow is ditferent tlsan the permit app!"icanl, e.g. praperty Darner. the Party <br />must adatowiedge this <br />response the bilimg by signature and data below- /� --7 <br />trAIIIE iIT7f Q ONE # _C/ u l A <br />EH23DO38 (revised 8MM) <br />F <br />EPA Site # <br />Project r ntacc 8. Telephone > - <br />c <br />Facility Name ' 7 <br />Phone — % <br />t <br />Address b <br />L <br />t <br />Cross Street <br />T <br />y <br />owner/Operator <br />Ptwne # <br />o <br />Contrador N <br />�o # ':�Zo 9 i <br />N <br />ContractorCA <br />U.Class A.I <br />R <br />Work Comp <br />Insurer <br />A <br />T <br />ICC T 's Certification Nun -bar <br />Expiration Dais <br />. Da <br />RICG <br />Installet's Certification Ntrnber <br />ExpuaLon Data <br />Tank Ip # <br />Tank Size <br />Chemicals Stones <br />Cunenity/PreviorslY <br />Dale UST Installed <br />T <br />A <br />w <br />K <br />UApproved <br />L�lfl ,,ed IW0- conditions UDisappmved <br />P <br />L <br />A <br />(See Attachwnt With Conditions) <br />N <br />Plan Reviewers Name <br />r Date <br />� <br />MUST �OBiI.ALL 1l�RK L+L_ <br />SARipACyJQ�rL UINTX. .SLATE. AIY� AH` ANDRB(IEAT7�fS;{ SAN <br />_... <br />SIGAIATU RE CERTIFIES THE F=OIAQ43- "f CERTIFY THAT N <br />.IOAGM OOLWY, EWROMIENITAL W-ALTH �. MHDR OR LJMZ D AGEIVS <br />IEf2W IS ISSI I S iA L NOT EMPLOY ANY Ply N SUCH A YAN4ER ASTO BENE SUBJECT TO <br />THE PE RFORLWICE OF THE WORK FOR Wfi1CH THIS . <br />WORKEI S CCXWPE "aATEN LAWS OF CALfFORI V COtFRACTO R'S HRWOR SMCONTRACIM. SMATLIRE CERTIFES THE FCILONVIr G '9 CERTIFY <br />A THIS PERLIF IS MM, 1 SHALL EMPLOY PERSaM SUB.EC TO WORKERS CaUPENS&TTON LAWS <br />THAT <br />IN TFE PERFCI M E OF THE W OFM FOR V*Kf <br />OF CALIFORNA.' <br />Tlis Tae <br />BIWNG INFORMATION-. <br />indicate the responsible party to be billed for additional EiD staff fine expended beyond permit payment coverage per tank- If <br />the party designated betow is ditferent tlsan the permit app!"icanl, e.g. praperty Darner. the Party <br />must adatowiedge this <br />response the bilimg by signature and data below- /� --7 <br />trAIIIE iIT7f Q ONE # _C/ u l A <br />EH23DO38 (revised 8MM) <br />