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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQU N COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELONG <br /> UTANK RETROFIT UPIPiNG REPAWRETROFIT LJuDc REPAIR/RETROFIT <br /> F EPA Site# Project Contact&Telephone# �4C4'j -&/-tq�,3 I C a r"r C r_ <br /> A <br /> C Facility Name �h < t YY�1ti Phone <br /> Address <br /> I Cross Street <br /> T <br /> Y OvenerlOperator K k's h rti2 r r rl - Phone# Cti l <br /> Co Contractor Name -� Phone# ),, <br /> yl / <br /> T Contractor Address j epi t� l.0 i�'I�a CA tJC# C C, `j(p Class{,� C 10, <br /> -�) <br /> R <br /> O- <br /> R , <br /> A insurer r.u1�0 Work Comp#eooc,5 C�i <br /> ICC Technician's Certification Number tion Dam <br /> `7 6, ?� I m t� <br /> O <br /> R ICC Installer's Certification Number 6*afion Date <br /> Chemicals Stored <br /> Tank ID# Tank Size CurnentlylPreviously Date UST Installed <br /> T <br /> A <br /> w <br /> K <br /> p UApproved roved with conditions UDisapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name v <br /> APPIJCAWMLISTPERFORM-ALLIODML+L.4 7l W-Ii^_ANJLIAPkWpgArTY rADXE-S. LTE1 Af<SANQRIA E-'-.AM_REC�IAl1T70rpLS.,CF�/W <br /> 3OAQM COLRJTY,ENVIRONMENTAL FLA TH JEPARTMENT.OiMM OR LKBEED AGENTS SIGNATURE CERTIFIES THE F+OLLOMC '1 CERTIFY THAT W <br /> THE PERFC PJAANCE OF Tr E WORK FCR WHICH THIS PERMIT IS ISSUED,I SHAIL NOT EMPLOY ANY PERSON W Sl1Cr-r A MA ER ASTO BECOME SUBJECT TO <br /> VUCRI(FR'S COMPENSATION LAWS OF CALIFCRNIA" OONTRACrars H JW OR 9A3coNTRAcrm smATURE CERTIFIES THE FcuD I oa 9 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR VVHIC H THIS PERMIT IS ISSLED.I SHALL EMPLOY PERSONS SUB.ECr TO MRKERS COL63ENSATION LAWS <br /> OF CM1FCRMA.' 6 1 <br /> Appficarft <br /> ' 7i 4 �; -R �� C ""..,L'RI�rC d. ' i.'1.fr''rA-1:1D31C (✓` <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff terse expended beyond permit payment coverage per tank If <br /> the party designated bekm is different than the permit applicant, e.g. property owner, the party must admowledge this <br /> responsibility for the baling by signature and date <br /> � below- <br /> ( <br /> -{aj �7 <br /> ADDRESS �3 LL) i4 ux:..m r, c k-lam►-, , C(`� <br /> SIGNATURE \,aL_i� C c.tiir L 1 <br /> EH23DO38(revised 8/806) <br /> 1 <br />