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T <br />A <br />N <br />K <br />p <br />A <br />N <br />00 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave_ Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />STORAGE <br />TANK RETROFIT KP RES *0 DAYS VR,,)kA <br />PIPING REPAIRIRETROFIT <br />EP , A - Site # I - U - DC REPAIRIRETROFIT COL 1 0 STAR VR UPGRADE <br />PrOlOct Contact Telephone # <br />Facility Name L - <br />Adores$ i Phor)e P <br />Street <br />OwnerlOperator <br />Contractor Name <br />Contractor Address 1"3( o" <br />insurer <br />11LA; technician $Name <br />I KX Installer s Name <br />Tank system work area <br />TanF, <br />Approverl <br /># <br />'iqlq UA Lic # <br />Work Comp <br />- <br />Expiration Date <br />2- <br />E Exp,ratjor', Date <br />"e— Store(! Date UST <br />proved witi c0ijdjr,,_,,, <br />See AZIChMent With GOTICVt rmc' <br />11 ) r S :-- 11) I'd C' V e a <br />Indicate the resbc)ns;l) IF' party to be 011lecl for <br />the party GeS'gna!E;,o nelo, IS different th� <br />FeSPOnSibility for the 011hng by signature,, <br />NAfvtE <br />SIGNA <br />EH -'3"('38 i fevlSeCi Oa 17' 4114 a <br />trot -t PMATION <br />ditionai EHD staft 'r('le exPenclel beyond perry -lit oaynlen? coverage per tank <br />if <br />the Permit apolicarlf e q <br />below propertyownp, the PaI`TY Most acKnOwledge this <br />1H UN F 4; <br />I-ENVIRONMENTAI <br />