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ENVIRONNONTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> East MaW ShW4 Sftclilen,Q*feruia 9RO2 <br /> T h e:( )4C&3420 Fa=(2")4C&W3 <br /> APPLICATIONFOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> t THIS PERMrr EXE'PIIIRES 110 DAYS FROM THE APPROVAL.DATE INDICATE PERMIT TYPE B-OW: <br /> UTAw L6PiNG REP IT Ucmc RBjAI STAW)E-VR UPGRADE <br /> F EPA Site# Pro Contact&Temphorie# <br /> A <br /> C Facirdy Name 5-TC. 5 % O <br /> I ress <br /> L Add <br /> T Cross Street 1 S ftb <br /> Y !SW ."S .. SSW, Phone# (ei7 4b <br /> CContractor Name Pune <br /> (moi 367 <br /> T Con Add 2-3`7o CA Lic C <br /> �' '?'? $026034 D 40 <br /> A Insurer ,CA Work camp#WCA3004S t ®i <br /> T ICC Technician's Ce n Number , / Date l+IA 19/2,01 <br /> R ICC Installer's Certification Ncenn apt ®y7- to d"7/'3i/?Aio <br /> micals Stored <br /> Tank ID#1 Tank Size CCurrrrently Date UST Installed <br /> T <br /> A <br /> N <br /> K <br /> P BApproved LJApproved with conditions UDisapproved <br /> L ( A ) <br /> A <br /> N Plan Reviewers Name <br /> i <br /> APPUCANT MUST PERFC RM ALL WOW IN ACCORDANCE WITH SAN"MAN STATE LAWS AND IRULES AND REGULATIONS OF SRN <br /> JOAC AJIN OOUN1Y,ENVIRONMENTAL HEALTH DEPENT OIAWER OR LICENSEDA : "I C EFMFY THAT IN <br /> THE PERFORMANCE OF THE FOR THIS IT IS I NCST IN SUCH A AS TO E TO <br /> VVORIQRSCOMPENSATION <br /> LAWS OF <br /> CALIFORNIA" <br /> CT HA2 OR ACTINGS CERTIFIE8 TIS FOLLfVG: "{CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR YM ICH THIS PERMIT IS ISSUED.i SHALL EMPLOY PERSONS SUBJECT TO ER'S COMPENSATToN LAWS <br /> OF CALIFORNIA" <br /> BIWNG IMF I <br /> indicate the responsible party to be billed for additional END staff time expended1beyond permit payment coverage per tank If <br /> the party designated below is different thart the permit applicant a g. property owner, the party must adcriowledge this <br /> responsibility for the billing by signature and dais below. <br /> NAME 5}_ TITLE---629&.0912-= pvomE , (09 <br /> ADDRESS_ ?,3-70 L.00-x% CA cha4o <br /> SIGNATURE <br /> EH (ravised 12131107) <br /> I: <br />