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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3410 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 />I i I I-.- .._ I L w e Rr-PAIR/RFTROAT <br />pPPU03 s�grau'r — - - <br />SIWNG MRMATiON: <br />indicate the r sdile party to be billed for additional EHD staff fine expended beyond Permit Payment coverage per tank ,f <br />the party nated below is different than the permit apptKant, e.g. property owner. the .pally must adaiowiedge this <br />respon <br />ay <br />the b rM by s- nature and date below. <br />Sac/' y D� <br />NAME Tl 1ma c. PHONE! <br />armRESS <br />SIGNATURE / <br />EH23DO38 (revised 8MM) <br />1 <br />'z <br />uuwn rc u.. - ---- ---- <br />F <br />EPA Sim # Pre' Contact & Telephone # <br />A <br />Facility Name <br />Phone # 7� <br />I <br />Address Q <br />L <br />I <br />Cross Stmt <br />T <br />Y <br />OwnerlOperatnr <br />Phone # <br />C <br />Contra arae 8 Phone # <br />0 <br />CA lac # MISS /� 9 d <br />Contra r �' <br />T <br />R <br />- <br />hisu <br />VNorK Comp # 6 <br />A <br />TiCC <br />T Cert�ation Number <br />Expiration Da>e <br />'s <br />R <br />ICC lr�Ner's Certification Ntanber <br />Expiration Date <br />Tank D# <br />Tank Size Chemicals Stored <br />CimentlyAlrei!ioisy <br />Dale UST installed <br />T <br />A <br />w <br />K <br />� ved with c ociditions ' �Pir�� <br />P <br />L <br />A <br />(SeeAtta�ntWith Conaions) �f <br />Ql./ <br />(V <br />Plan Reviewers Na ( Dais <br />APPLicAL� MIDST t.Ayt !bL- __ -. ccxm[7xpr o rne> s,..su+ ;ne[� x s.A _r cltnT�anls:c sntr <br />OR LM3SED AGENT'S S1C3t ATURE CEIRTIFiES THE FOf.LM943: "I CERTIFY THAT IN <br />.IOACLAN COUNTY. ENVfftCXNIiENTAL HEALTH DEPARTMENT. <br />IS M", t SNAIL NOT EMPLOY ANY PERSON IN SLX]-I A MANNER ASTO BECOME S M IECT To <br />THE PEIRFORMUWCE OF THE WORK FOR WHICH THIS PERMIT <br />WRING OR SLIBCONTRACTOIS S13WTURE CERTIFIES THE FoLLovw4a n CERTIFY <br />WORKER'S CCMPEm&TION LAWS OF CALFFORICk CONTRACTORS <br />PERMIT IS MW I SHALL EMPLOY PERSONS SUB ECT TO WORKERS OOMPENSATION LAMS <br />THAT IN THE PERFORMANCE OF THE WORK FOR V*OC H THIS <br />OF CALiFORNA' <br />Owe <br />pPPU03 s�grau'r — - - <br />SIWNG MRMATiON: <br />indicate the r sdile party to be billed for additional EHD staff fine expended beyond Permit Payment coverage per tank ,f <br />the party nated below is different than the permit apptKant, e.g. property owner. the .pally must adaiowiedge this <br />respon <br />ay <br />the b rM by s- nature and date below. <br />Sac/' y D� <br />NAME Tl 1ma c. PHONE! <br />armRESS <br />SIGNATURE / <br />EH23DO38 (revised 8MM) <br />1 <br />'z <br />