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• <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQU N COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3410 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT E)TWES 90 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT' TYPE BELOW <br />1%4 - _ i L— - oc =Mr Tun[tT Lim REPAIRARETRORT <br />Appbcarts - J rYvv .� - - - <br />BIWNG INFORMATION: <br />indicate the responsible party to be billed for additional EHD staff the expended beyond permit payment coverage per tank.. If <br />the PAY designated below is different than the permit apprirant, e.g. owner. the party roust achwwledge this <br />responsibility for the biking by signature and date below_ <br />tE( L f i� 1��r1 Yc�c�ic✓-nTLE•�:-rL;;c <br />ARESS — 15' �, CLYr L <br />T <br />EH230038 (revised MW) <br />;INIANK bit IKU H u...............�....�...,.._- <br />F <br />EPA Site # Project C nt d & Telephone # <br />A <br />Facility Name {�, i �S" <br />Phone # jo ? <br />Address `' D �; tI f <br />I <br />L <br />I <br />Crass Street <br />Y <br />owner/Operator :. c `taL <br />Phone # <br />Phone # <br />Contrador Name C r v - <br />c <br />0 <br />N <br />F <br />ContradoC Address " �' c CA ! is # (a? Vv 10 <br />T <br />AInsurer <br />Wlorkt;omp#^ <br />C <br />T <br />ICCTedutician'sCertificationNumber ,l S S'7CL (,'r" Expiration Data <br />R <br />ICC kmul et's Certifimbon Number Data <br />Tank Size Chemicals Stored Date UST Installed <br />Tank !D # Currently/Pceviously <br />T <br />A <br />u <br />K <br />Ipmved <br />LIApproved t' o.d with conditions <br />L <br />(See Attadmlent With Conditions) <br />% <br />N <br />Plan Reviewers Name tilA�Q R� Date <br />ret_-ACCPR &s;E- ..sAtt.s atm Y CRDu raaa_E-s,_srnz t nous geQ r rt€s n _ a►T rs of sot t <br />AppSlCpt1[ MUST PEEREE(J _ cSUF IFS 7F� POLLO M-- '1 CEFriFY TMT MI <br />oNmE rAL H CVMER OR LMSED AGENTS S03MTURE <br />IOAQtJEN COIR frY, F0F TH A8r43� F HEALTH M34RTMSdT. <br />TME PEWCRMANCE OF THE WIORIC FOR VVHI I TMtS PER11rT is tSSi)E31, t SHALL NCIT R fiPLUY ANY i Rsol+t W Si1Cl R A tdAACJBt ASTO R 1+tE S1161EI T TD <br />SIGWATURE CERTWIPS TME 1101-10t I G '1 CQ7TIFY <br />VX%zaj 'S COMPetSATIM LAWS OF CALIFORI CONTRACTOR'S WRING OR ajx-j NTRAGI3�G <br />OF THE WORK FOR V*-IKH7 INIS PERMIT IS {SSIM, I SMALL EMPLOY pa;MC � SUB.ECT TO VJOWCERS COMPENSATION LAWS <br />THAT IN THE PERFOR JAANCE <br />Cr` GAt3FORMA" \�/ Jct �d / �. (� [���- <br />li._�/l �,1i�1 �i t htr iYL: [lie <br />Appbcarts - J rYvv .� - - - <br />BIWNG INFORMATION: <br />indicate the responsible party to be billed for additional EHD staff the expended beyond permit payment coverage per tank.. If <br />the PAY designated below is different than the permit apprirant, e.g. owner. the party roust achwwledge this <br />responsibility for the biking by signature and date below_ <br />tE( L f i� 1��r1 Yc�c�ic✓-nTLE•�:-rL;;c <br />ARESS — 15' �, CLYr L <br />T <br />EH230038 (revised MW) <br />