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Ll <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUINORECEIVES <br />1868 E. Hazelton Ave., Stockton, California 95205 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 NOV 0 8 2016 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTF <br />DEPARTMENT 1 . <br />THIS pERmITEXpIRES 180 DAYS FROM THgAPPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT J(UDC REPAIRIRETROFIT 0 COLD START/EVR UPGRADE <br />signatureBILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by <br />�k -nTLE t-[kCQ` PHONE {24-7 <br />I _— —11dML <br />an <br />EH230038 (revised 7-26-2016) 2 <br />EPA <br />Project. Telephone <br />`• - 1 J! l' <br />Contractor Ad <br />t: <br />. <br />/ <br />Technician's . <br />• . i <br />0 <br />R <br />OVA <br />Expiration Date <br />Tank system • <br />Chemicals Stored <br />i(See <br />x+: <br />i. <br />P.e- 87 piping sump. 91 detector. UU4 air,) <br />Approved Approved With conditions Disapproved <br />Attachment With Conditions) <br />G <br />Plan>F. e.. :. .. .s <br />NamI(j <br />�. •. .. � ,f C � <br />Iy /jj <br />j <br />signatureBILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by <br />�k -nTLE t-[kCQ` PHONE {24-7 <br />I _— —11dML <br />an <br />EH230038 (revised 7-26-2016) 2 <br />