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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 REPARIRETROFIT REPANWRETROAT <br /> F I EPA Site# Project Contact&Telephone# <br /> A �` <br /> C Facility Name Phone# LLJ <br /> I <br /> L <br /> TCross Street ^ ..� <br /> Y Ownedoperator Phone# a • (4 ba <br /> C Contractor Nannie •( Phone# (:9001 (� 7 <br /> N W�I- <br /> T Contractor Address !; , # Class I � <br /> AInsurer Work Comp# <br /> T ICC Technician's Certification Number <br /> Expiration fate <br /> R ICC InstaWs Certilicafion Number <br /> Expiation Data <br /> Tank ID# Tank Size Chemicals Stored Date UST installed <br /> Curnently/Previousty <br /> T <br /> A <br /> N <br /> K <br /> P LJApProved Appromd with conditions UDisapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Rev;�Name <br /> Date <br /> APPl1GANT 1iL1S7Oe#t.Att .. _L►+t 9CXX)EiflAi 1ARTFl.SAN J JdIDOi R[TX.OR�NAT E s99F!AVM AN[)._ S AND REC�LATIONS,OF SAN <br /> JOAC]tAN COUNTIROPBABY> HEALTH DEPARTMENT.OWNER OR LlCassm AGE r s siGmTuRE cBmFfES THE FOLLovA4GG .1 CERTIFY THAT NJ <br /> THE PEitFORlulANCE OF THE WOf2fC FOR V4Fi1Cbl THIS PERMIT 15 M%)ED,I SFWL NOT EMPLOY ANY PERSON IN SUCH A MANNER ASTO BECOME SLIMIECT TO <br /> VK7RKF1;rS COMPENSATION LAM OF CAL1FORNIk' CONTRACTOR'S HIRING OR SLOCUffRACIM SIGNATLRE CERTIFIES THE FC&LCVVWG: 'I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR VN-11C7-i THIS PERMIT IS ISSN,1 SHALL EMPLOY PERSONS S-E ECr TO WOWER'S TION LAWS <br /> OF CALIFORPIIA' <br /> Tdte Dale �J 1 <br /> BIWNG INFORMATION: <br /> indicate the responsible party to be billed for additional END 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 this <br /> responsibility for the billing by signature and date below. <br /> NAME ® � Cot X11 ISI �TITLE7Q— (0'a ��� <br /> ADDR L <br /> SIGNATURE <br /> EH230038(revised 8MM) <br /> 1 <br /> I <br />