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- - -EAi WWAQ MENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone:(209)468-3458 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> 't 7M PERMR E*IRES 90 nAYS FROM THE AMWAL OA7E W WCA7E Pati rr TYPE!BELOW <br /> UTMI(RE MOFRT L P7PWG REPAR/RE7 m r i— RFPA1WRErRoRT <br /> AF EPA Site# Project r-q§ t&Telephone# <br /> C FacTty Name <br /> LAddress Z V _ Phone# <br /> I <br /> r Cross Street j <br /> Y Owner/operator, <br /> C Phone# <br /> 0 <br /> Contactor Name <br /> N _�� <br /> TT ContracmrAddress CALic# Class <br /> A insurer <br /> C Work comp#C� 3 <br /> •" ' _ <br /> T 'CC Tec v*ian's Certification Number <br /> o Expiration Dais <br /> R ICC lnsaws Cerbtication,Nwrdw <br /> Expiation Date <br /> Tank ID# Tank Sire Chemicals Stored (late UST installed <br /> Currenlhr/Previot�iy <br /> T <br /> A <br /> M <br /> K <br /> L pf°� vier conimons UQis <br /> approved <br /> A (See Attadtment Wrlh Conditions) <br /> N Plan Reviewers Name <br /> Data <br /> APPtlGAt+tI YL2ST /{(j_.yy mr iiwnr+el�� t it6�,.r09rX1QdC0[Rt173! <br /> JOAO=COUNTY, ` <br /> EN�/62ON8lHWiAL WEALTH DMART618,r1:6WNB2 OR UMMED AGENM-- —�-�TATELANtSi/1�[2,B1, �S.A89.RFar^�Elanete:C7F„^.,sAf�1 <br /> THE PSWURMN4MOF Tr'E VIK1FbC FOR WHIG I7I QSA YAM1ASTO PERW IS IMLIED t gPLOY ANY <br /> PatSM W SIO l 82 T71� <br /> VIIC)RI�S CISAT1�1 LAW OFCAtJFUt' CONTRIK;TIT IYRIAIGOR <br /> THAT A�OF 7HE YIR7W FOR W*Ctr'[M PERI fT IS MUED IPfftSONS SU@ EGT TIDN L/tWS <br /> APPS Toe <br /> .Gate <br /> SIWNG I RMATION: <br /> Indicate the responsible party to be billed for additional EFID staff fine expended beyond <br /> the Ply designated below is Werent than the Y Permit payment coverage per tank If <br /> respon{siibft for tthe'SbdroV by sgnahrire aan�d�date 1,� 1, e-g- Property owner: the .party m� �e this <br /> NAME l._�� � t �I, (� AL-bL —TnLE WiONE# LS.�C Z <br /> 0 `c ) <br /> nDnlr>; S 1`i 1 l-tl l,�Af� �1� ►;(':Tc�rl+ clSc � <br /> SIGNATURE \a <br /> 6423D=(revised avos) <br /> 1 <br />