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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAKI JOAQUN 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 APPIWAL OATS NG <br />WDICATE PERMIT TYPE BELO <br />KANK REMOFiT UPWING REPMWEMORT REPAIR/RETRDRT <br />a <br />I F I <br />EPA Site # Prejed c4rdact & Telephone # <br />A <br />c <br />Facl�iy Name �`o r n iH .} Phone �aCl — o� <br />' <br />Address Qq c5, rytan CA '1 <br />L <br />I <br />T <br />Cross Street <br />/ <br />� Phone # ' rOZ5 <br />Y <br />OwnerfOperator <br />Phone #ad�R - �/q� <br />Yc' �7'!"c Contractor Name <br />O <br />TCA <br />Vi <br />Address 3S L C1YY. lJY CA i�c # (p �C j (o C i� <br />R <br />r�G r Work comp #� UUO S 61-)75! <br />insurer T k�oa "� V—rt'kXCW <br />A <br />T <br />ICC Techniriaws Certification Number 9 _ �� J k % doo <br />R <br />ICC Installer's Certification Nurnber <br />Expiration Date <br />Tank m # <br />Tank Size <br />Chemicals Stored <br />Currenty/Previo=4 <br />Dale UST tnsta>ted <br />T <br />A <br />W <br />K <br />L]Appmved Approved with conditions UDisappmved <br />P <br />L <br />(See Attactw t With Conditions) <br />A <br />D�N <br />, " v I t7at® <br />Plan Reviewers Name <br />MCML�L90.sMiR-IA1,t.lO�dUa¢COUb[IY.�,ZTAT€ AMU RIK AM -RSCA ATIONs;OFSM <br />APF3JCAt tT MU&T i�ERFC t At! ac? UCSD S131, ATURE 61JR&IM THE FOLLC7J191G_ -1 CERTIFY THAT IN <br />"GLM COM", E?0JIR01�TrN- S ALTN pART6rBdT.OVAER AGENTS <br />THE PERFORMANCE OF THE WOW FOR V*fCH THIS PERMfT IS ISSUED, I SNAIL NOT EMPLOY ANY PERSON IN SLK3EI A UMNER ASTO Ba =COME SUBJECT TO <br />SIGNATURE CERiiFIES THE FCUD AI IG 'I CERTIFY <br />VgrO RHT=R`S COMPENSATIC:N LAWS OF CALIFORtW CONTRACTCRS HRMOR aj3-CJONTRAL"iA1C' <br />OF THE WORK FOR WHICH THIS PERMIT IS MM 1 SHALL EMPLOY PERSONS SLJ&ECr TO WORKER'S COMPENSATIDN LAWS <br />THAT IN THE PERFORMANCE <br />CF CALIFORMA.• <br />zl;dp - <br />BILLING INFORMATION: <br />indicate the responsible party to be billed for additional EHD staff bne expended beyond Permit Payment coverage per tank if <br />the pasty designated below is ddlerent than the permit aWrmant, e.g. properly owner, the party must admawledge this <br />responsibir fdr the <br />..� baring bysignature and date below. i7LE4 <br />Lv� �/ <br />A )l a e -�/ <br />PTI E <br />EH230038 (revised amm) <br />