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Y t 0 ! <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95242 <br /> Telephone:(209)468-3410 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS pBIWT EXPIRES so DAYS FROM THE APPROVAL DATE INDICATE PERMfT TYPE BELOW <br /> UTANK RETROFIT UPIPING REMPRETROnT UIM REPAtR/REU ORT <br /> Pro ne# <br /> h <br /> l <br /> Contact&Teepo / <br /> F EPA Site# �� fU <br /> C Facility Name 1 Phone# 1 <br /> -4 d <br /> L Address <br /> I Cross Street <br /> TPho <br /> om ` - <br /> Y Owner-Operator <br /> C Contractor Name <br /> 0 i . <br /> N Contrac4or Address ` CA tic# -7 Class A- <br /> T ry`�, <br /> R Insurer r _ Work Come#PhOf -- <br /> A <br /> C ICC Technician's Certification Number Expiation Data <br /> R ICC Installer's Certification Number + rj L �/ - Expiration Data <br /> Tank Size Chemicals Stored Hate UST Installed <br /> Tank ID# Cwrent:ylPreviotsly <br /> T <br /> A <br /> to <br /> K <br /> P L-JAppi wed L Waned with conditions UDisapproved <br /> L (See'A32actunent With Conditions) <br /> N Plan Reviewers Name UA Date <br /> VUDRIC L�t 40 SAN fC]6lXJIAItXX�[TY. .SIhTE LAY S.A BIx€S ASD-REDIA CERTIFY <br /> TH SAN <br /> JOACICAttr 1!LLST EINR t Ail OMt�lER OR iJCE1SSED AGRC S SKSVAILRE CITIFIES THE FOLLOIhM 9 COY THAT IN <br /> TVE PERFORMANCE <br /> OOtRAN ETEViTHE WORK <br /> F WALT"DEPARTtiBdT. <br /> Ti!E PEiiFORtJtANC£OF THE YVORiC FOR WHICH TTiRS PERMfT IS tSSUED,t St TAIL NOT Ef1Pt 0Y Ar1Y PEf25Cx+1 W SiJC>{A i6Ai E B2 HE FC Z3E VMG -1 CERTIFY TO <br /> V LAWS OF CALfFORMA.' cou RACrORS HRWOR S�NTRAO� TURE <br /> THE fOILOVVNG "I GI3ZT}FY <br /> THAT E?S OF TIC VVORIC FOR VAjcH THIS PERMIT IS ISStM 1 SHALL E PEI== VVORKFRS COMPENSATION LAWS <br /> CF CALIFORNA7 <br /> APPT�� e i Tdfe <br /> , <br /> BttlltJG INFORMATION: <br /> indicate the responsitile party to be billed for additional END staff fine expended beyond permit payment coverage per tank- if <br /> the party dbelow is d"dferent than the permit applicant, e.g. property owner, the .party mustt)acbxwrledge this i pt tE7 <br /> responsibility forbillitig by mature and date below_ I / �Y <br /> NAtrtE h / nnl I <br /> -r <br /> ADDRF�S t C l}/ll},JJJ' <br /> SIGNATURE <br /> EH230038(revised af8M) <br /> 1 <br />