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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 PaUXT EXMRES 90 DAYS FROM THE APPROVAL DATE, INDICATE PERMrr TYPE BELOW <br />�ttANK RETROW UPIP;NG REPA fiZEMOFIT i um REPMRA?EMORT <br />F I EPA Site # ProjectCanfad & Telephone # <br />C Facility Name f)ffl- Phone # '%/IQ P4 0- <br />I <br />r <br />L <br />Address <br />I <br />1 Cross Street <br />T <br />Y <br />I OwnedOper.#nrjr)PodijlQ <br />Phone # <br />C <br />o <br />Contractor Name l f <br />Phone # _ <br />TContractor <br />Address <br />Q CA tjc# �(J 7 Class <br />R <br />r <br />Insu76(chnician's <br />Work Comp # <br />I W <br />T <br />ICC Certification Number <br />Exptratio�n Data <br />R <br />ICC InstalWs Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Cunently/Previously <br />[cats UST Installed <br />T <br />A <br />N <br />K <br />P <br />L+PPmved <br />04pP'°wd with conditions UDisapproved <br />L <br />A <br />(See Aitaclunent With Conditions) <br />N <br />Plan Reviewers Name A&�, <br />path_ <br />APP11( �4nlT 1v[LLSTP11 L1E2i1r. N1.Y510E2KLMA AMC S6Qi1J^aAM..109Q11NLX�IX�rTY-.Q!%LYNAt,ImRs.STAiEiyNNMr..Rt BI$I S. ALB-REG4hATiONS:OF.SAtI <br />"CL IN C=4TY, ENV:EiD�AL WEALTH DERARTMSJT. CANER OR LXBJSED AG RCS SGMTURE CSMFIES THE FO LOYAC: -t C SMFY THAT IN <br />THE PBRF�E OF THE WORK FORY4ff M THIS PERMIT IS iSbiEa t SHILL NGT EMPLOY ANY PERSON IN SUCH A MAN JEER ASTO SME SUBJECT To <br />VVCR EFM CONPe"TION LAWS OF CAU;3ftAr C ONTRA=RS RPJWOR SUBCONTRACrM SrARTURE CERTIFIES THE PDLLOftJG: 9 CERTIFY <br />THAT IN THE PE WMMANCE OF THE WOW FOR WHICH THIS PERMIT tS ORM, t SHALL EMPLOY PEP=W SUB.Ecr TO YYowERS C oMPENSATION LAWS <br />OF CACIFOWk" C <br />BIWNG INFORMATION. <br />Indicate the responsible party to be billed for additional EHD staff fine expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit apprmnk e.g. property owner. the .party must acbrowlerIge this <br />responsibility for the billing by signature and date below. <br />IME b1 m -nnE MIONE # 40 <br />EH23DO38 (revised 8MM) <br />