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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN 3OAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone:(209)469-3420 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> ``�11 T=PaZWD"RES 90 DAYS FMU TW APPROVAL DATE Par—ATE PERMMTYG PBE rW <br /> LJTANKRt`TRORT UPIFING REPAIRWIRORT UtlDC REPAIRMETRORT <br /> F EPA Site# Project Cantad&Teledmne#' <br /> A <br /> C Fatuity Name Phone# <br /> t Address , <br /> L Geio <br /> l <br /> T <br /> cross Street <br /> Y Owner)operator <br /> C ContraName Cant-actor N <br /> O Phone# <br /> NContrac�rAddress C `t <br /> T CA LX# Call <br /> R <br /> A 'm" i�I^�r 1-�15fA�a ce Gfl. W0*comp# W PLSC��r 3i —[acs <br /> C <br /> T ICC Tedmician's Certification Number <br /> O - I=XpRabDI1 Ddb9 <br /> R ICC)nstalier's Certification Number Expirafan Date <br /> Tank ID.# Tank Size. _ ChemicalsStored_ <br /> DaA-UST Insta@ed- <br /> _ Cuneoi[ylPievioiisf _. _ _- .. <br /> T <br /> A <br /> u <br /> K <br /> r6ved with CondiSorrs UDisapProved <br /> AL ( Attachment With Conditions) <br /> N Plan Reviewers Name ' 6. <br /> Dais <br /> APHJCJILtir71tL5TP.ERF[YtuNt_16�R1CM-AGCY]62f1e�rsyKstiaCeu���Zr[]ante*rrc_a�2Edd1NfS,Ar+Q2. At1D <br /> .k34OUGd CX jwy,AWIANC SAL HEALTH LEPAR 11tENr 01MJD2 OR LtC�rSED AGB IT S SK VQLktE CDS THE FLY LOYWCIRK1tFK, ry cEff nFY THAT IN <br /> TFEIOFTf�LM65FORV*=HTWSPERWr1ST'SNALLµDT AN1PS�tSM 4aaiA1tMQ ASTODE�ESaIECrTO <br /> WC7fiKHiS COIIP9JSATIQN LAIM1fS OF CALIFO*W WMRAC WS FTIROYS OR SUBDONTRACTM SIC.ALITURE CERTIFIES THE Fi7LL MMKIC- 9 CERTIFY <br /> CF CALF RNM' VCE OF THE VIR7Fi}C FOR WHIC7 r TFrIS PSUtI;IS tsSl ID r S 4kL BFLOYf SUBK-Cr TO YK WERS OMFEICATION LAWS <br /> CF cal�RnaA.- <br /> BIWNG INFORMATION. <br /> Indicate the responsible party to be bilied for additional B-ID Stafffine ne expended beyond permit payment coverage per tank. If <br /> the party designated below is deferent than the permit appk2rit, e.g. property owner. the .party must admowledge this <br /> responsbifLty for the lining by e signature and datbelow. <br /> NmE i sim k13MIC) T?TLE <br /> SIGNATURE Ch l� Yl 1 UC <br /> EH23DO38(revised 8JBW) <br />