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VIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN COUNTY <br /> 384 East Weber Avenue,TZuid Floor,Stockton,California 95202 <br /> Telephone:(289)46&3420 Fax:(209) 3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TINS PERMIT EXPIRES 90 DAYS FROM THE AMMAL DATE.JIMICATE PERI"TYPE eELOMt <br /> L TAw REmow Llqmw.REPmuRETRm>E•TT Umc REFArr mErRmT <br /> F EPA Site# Project cwt d&Telephone# <br /> CFacft Name Ptwne# <br /> t Address <br /> L <br /> t Cross PKI <br /> Street <br /> T <br /> Y Own c Phone# •: <br /> C: <br /> Contractor NamePhone# <br /> O --V- <br /> T <br /> - <br /> T Gonfiactor Address CA Uc# /Vamlb cbssAbUb <br /> AInsrtter Work Comp# L - j <br /> C: <br /> T ICC Tedvikvvs Certification Number Eisation Deeds <br /> O ICC s Number D <br /> R <br /> Cliernicals;Slaved <br /> Tank 9)# Tank Size Curn'nt<y nab UST <br /> InstalledT <br /> A <br /> H 1 = <br /> K <br /> LJAppmned Vft ..FnS LAYisapmved <br /> L Wdh Conditions) <br /> A <br /> Plan Reviewers Name z Date <br /> APPt1C.AhtT MUST __ ALL.Y{PW. .. A� -VS. <br /> AN A6B _._.._... _._..;�`�► <br /> JOAOLCC L*ffY, _..._ ...._. _..AL HEALTH CR LK�ED AGENM SIGMIXIRE CERTIFIES THE 9 CERriFY THAT 1N <br /> THE PERFORIdiANCECFTHE VYCWFaRVWH1CHTHIS PERMIT 1S=JED,ISHALL NOW1:LWLOYANY PERSMW&)CHA ASTO MMISE SMJEGTTO <br /> VdMIXR'S COK543IMTION LAMS O CONTRA CORS HIRMGOR SUBDON111ACTING SIGNATURE CERTIFIES THE -1 CERTIFY <br /> THAT IN THE CF THE VYORIC FOR V**CH THIS FiRwr Is mum.L SHALL EMPLOY PERsais sj&ECr TO=RKERs caupewAnoi L Awe <br /> CF <br /> Sigrshre TI11e D.A. <br /> SLUNG t RM 71ON: <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 bekm is different than the permit applicant, e.g. property owner: the .party must ackwwkxkje this <br /> responsi3ft for the bdkQ by signature and date below. <br /> NAME �,� <. TfT1 E X1 4. Q ( 1 PHONE# 1 _ <br /> ADDRESS Z (��� t 5� ��� s <br /> S,GNATLIRE <br /> EH23D=(revised BMW <br /> 1 <br />