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woo-1j6-mmm//:d:gq glsm luol}ewjotul sjow jod -jamas xe} jo�ewXyd IdE) Aq paA1939.1 Senn ° <br />ENVIRONMENTAL HEALTH DEPARTMENT MAR <br />SAN JOAQUIN COUNTY <br />1888 E. Hazelton Ave., Stockton, Caliibrnia 95205 <br />Telephone: (ZQ9) 488-3420 Fax; (209) 468.3433 <br />9 <br />APPLICATION FOR UNWROR+OUND STOMAOF. TANK <br />RETROFIT OR PIPING REPAIR PF-RMIT <br />THIS PERMIT EXPIRES 780 DAYS FROM THE APPROVAL GATS, INDICATE PERMIT TYPE, SSLOYvt <br />n TANK RETROFIT ❑ PIPING REPAIR/R971101`iT CI UDC REPAIR/Rg'TAOFIT o cQl_D START/@Vfi VMRADE <br />F <br />EPA Site # Project Contact 8. Telephone ft <br />A <br />Fatality Name Phone tr j <br />i <br />L. <br />Address <br />I <br />Cross Street <br />Y <br />Owner/Operator Phone # <br />© <br />Contractor NamePlane # <br />Contactor Address CA LID # Glass <br />7 <br />A <br />Insurer Work Comp # <br />IGC ToonNalan's ame EXpitedon Date <br />o <br />R <br />ICC Inatallel's Name Expiration Date <br />Tank system work area Tank Slze ChmmloBis Stored Currently Date U87 <br />Installed <br />p.s. e�aauV,et seams, UDC 112, mc.) <br />T <br />A <br />N <br />K <br />Approved ❑ Approved with conditions ❑ uteapproved . <br />P <br />L <br />(See Attachment with Gondttions) <br />A <br />N <br />Plan Reviewers Name path <br />APPLICANT MV$T PERFORM ALL WORK IN ACCOROANCE WITH SAN JCAQVIN COUNTY ORDINANCES, STATUS LASS, AND RULIM AND REOULA11ONS OF SAN <br />DEPARTMENT, owNER OR LICENBktb AOENT'8 SIGNATURE ORRTIP166 THE FOLLOWN1a: I CERTIFY THAT IN <br />jWUIN COUNTY, mWIRONMENTAL HEALTH <br />THE P4RP0RMAN06 OF THU WORK FOR WHICH NIS PERMIT IS 188UE0. I $HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A® tO BECOME S� KJIWT TO <br />CONTRACTOR'S HIRING OR SUBCONTRACTING 814NATURE CERTIM0 THE FOLLCW1NC; °1 CERTIFY <br />WORKER'S COMP$NWrl OF CALIFORNIA" <br />THAT IN THE PER 90 TKR WVRK FOR WHICH YHIN PWRMIT 1$SUED, I SHALL gMPWY PERSONS SUBJECT TO WORKER'S COMphNbATION LAWS <br />OF CALIFQIlNW" <br />A olcants VignstyrsY Date <br />BILLIN(A INFORMATION! <br />Indicate the responsible party is be billed for ed0donai EHD staff tlmu expended beyond parmtf payment aov"e per tank. If <br />the po ty designated below Is ditmnt than the permit applicant, e.g, property owner, the party must acknowledge this <br />responsibility for the bliiing by signature and date below.,�r--� <br />NAME Tn' t <br />EK23OD38 (mulsod 07.17.2014) <br />2 <br />INd 917:8Z:£ 9I OZ/0£/£ :ale(] I./l.:a6ed uMouNun :wojA <br />