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0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone:(209) 3410 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> Ito <br /> TMIS PERMIT EXPIRES <br /> ,?0 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELONG <br /> UTANK RETROFIT UmNG REPAiR1RETRORT UUDC REPAIWRETROST <br /> F EPA Site# Pmjed Csntact&Telephone# <br /> A <br /> C Facility Name b,�. Phone# ' —? ` <br /> LAddress <br /> TCross Street <br /> Y owner/Operator �. Phone# <br /> oContractor Name Ebie. i _ Phone# <br /> T Contracoar CA Lic# <br /> R 1 Class X,CZ- <br /> 1/6 <br /> A Insurer �' Work Comp# <br /> i 1) t 7 7 <br /> T ICC T 's Certification Nurter Expiration Data <br /> RICC InstaHet'S Cervication Number E,;*ason Date <br /> Tank ID# Tank Size Chemicals stored gate UST Ins <br /> talW <br /> Currently <br /> T <br /> A <br /> N <br /> K <br /> P UapPm ved� ins UDisapproved <br /> L nt With Conditions) <br /> A <br /> N Plan Reviewers.Narrq_ Da <br /> APPUCAW kVJST PE RFPW.AM K A09PRDANPE_AMLSAN.JP44M C:MON ._ ._..__. <br /> OAMM COLMITY,ENviRONMENTAL HEALTH DEPiARTMENT.C1AdIER OR LK�SED AGDIT'S S 8' a C THAT <br /> . <br /> THE OF THE WC7RK FOR THIS PERMIT IS ISSUED,I SNAIL NOT BMM ANY PERSON IN S XH A MAN4ER AS TO BECOME S MJEC T TO <br /> vvma rs comlem=N LAWS oF - CONTRACTORS HRMOR 9AXXAVTRACTM SIGNATURE CERTIFIES THE 9 CERTIFY <br /> THAT W THE PERFORMANCE OF THE WOM FOR V"CH THIS PERMIT IS ISMM,I SHALL EMPLOY PERKM SIIB.ECr TO VKW% S CoMpUMTION LAWS <br /> OF CALHFcwA." <br /> SIWNG INFORMATION: <br /> Indicate the responsible party to be billed for additional END staff tare expended beyond permit payment coverageIf <br /> the party designated below is different than the per tank_ s <br /> responsibility for the ted applicant e.g. p�� owner. the .party must a this <br /> / bitting by signature and date below. <br /> NAME f-f9 Eta TiT1 E_ iJ i� e f mit PHONE# <br /> ADDREss r k C <br /> SIGNATURE s, <br /> EH230=(revised 80M) <br />