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1. <br />0 MIS <br />4, <br />ENYhRIONMENTAL HEALTH DEPA <br />SANJOAQUIN COUNTY <br />i oo nst Miain Street, Stockton, California 95202 <br />Pif <br />Tejephonc: (209) 468-3420 Fax: (209) 468-34-33 <br />APPLICATION� FOR UNDERGROUND STORAGE TANK RETROFIT OR PINNG REPAiP. PERMIT <br />I THIS PERMIT EXPIRES 180 DAYS FROM'rHF APPI40VAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RET r'0q I IT n PIPING REPAIRMETROFIT n, UDC REPAIR/RETROFIT n COLD STAR TIF-Vr< UPGRADE <br />Project & Telephones F FPA SIte Or� <br />A Phone # <br />Fc- <br />fJ, <br />Ar , �Ss L <br />T <br />Y Phone # <br />Phone 6 <br />0 <br />N Lic N Class <br />Ccritrsctor Ad ss //j <br />FT' ' Insurei;/ 1, WorkOomp <br />A <br />IC -w Technichin Namei°' _5 7- Expiration Date <br />0 its;, Installs elmf Expiration Date <br />T,.?n, ystern work area Tank Size Chemicals Stored Currently Date LISTnstalle� <br />01 jkwk 0;JVWnr, UTA, Mrd, ift.) <br />A <br />K <br />---- — -- ---- <br />F) I I Approved I I Approved with conditions I Disapproveci <br />L (See Attachment With Conditions) <br />A <br />N til :n Reviewers <br />APPLiC11 T MUST PE71. M A 1. IN ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCE '$. V'rATE LAWS. AND RU I,ItS AND REGLILA I'IONS OF SAN <br />.IOAOUIN cOUNTY, r7MV1 CNIVII-.NTAL I IEAI.TH1 DEOPAKTIVIENT. OWNF,R OR LICENSED AGEN'r's 6IGNA'rURe, GERTJNJ[-:; THIS; FOLLOWING: "I "MKIII-V --I IAT IN <br />E <br />rl-fkz� VRr4r()RNIANCr. OF I I Ir WORK FOR WHICHHI <br />TS PERMIT IS ISSUED. I SHALL NOY EMPLOY ANY PERSON IN SUCH A MANNER AS TO DE -C01 VJ' SU13 F. I' <br />J C <br />TO WORK7!VS COMPI:NSATION I AWS OF CALIFORNIA," CONTRACTOR'S HIRING OR $UBCON'rRACTINQ SIGNATURE CERTIFIL,Z'I`Hr! ' FOLLOWING: "I 1:VIQ,nr-Y <br />Tf JAI IN I Al: 1`15=A�ONIVIAI, CIE OJ`THE WORK FOR VkHICI-I THIS PCRMII* IS ISSL)EV), I SHALL EMPLOY PERSONS SU15JECTTO WORK!"IR'S C0N1PENSA'n0,\1 LAWS <br />01- CAI IF:)F4NIA.` <br />indicate the response party to be billed for additional el -10 staff (Irne expended beyond peniiit paynien-, coveroge p-.�r tank, if <br />the p;.,r.y designa".od I below is diftrent than the permit applicant, e.g. property owner, thc- party rnLISt ecknowlefJ90 thiel, <br />R-spons2bilibi Vor th_- blling by signature and date below, <br />NAME_,,.,, <br />ADDRE:.4'S_., <br />SJGNATI.1'RI-.___ <br />(revisud':21720 n) <br />----TITLE;. __ ­­.. PHONk`m. <br />1. <br />90/TO 39Vd ADO-10NANVi 6179T996160Z 90:TT OTOZ/V@/TO <br />