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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN 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 />161 - - - <br />A Insurer <br />----- <br />work Comp # l �- ? - <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE IMNCATE PERMIT TYPEBELOWBELO <br />Expiration Date <br />R JCC InstalWs Certification Number <br />UTANK RETROFIT <br />UPIPING REPARREMORT <br />UJDC REPAIR/RETROFIT <br />F <br />EPA Site # <br />Project Cantact & Telephone #4 1. <br />e <br />A <br />G Facility Name C-avi p <br />I <br />L <br />Address <br />�1 <br />1. <br />Cross Street <br />T <br />Y <br />C NvrverlOperator <br />('A <br />Phone # r <br />Contractor Name <br />IPalfra <br />0,J <br />Phone # `t _ <br />oC <br />N <br />(`.ntrarj,,rAeieirn c <br />�� .� <br />i 1�: il. �i Inn (1,� 1 _ 1-AAi/- <br />ri.,..., lain A i n ri <br />161 - - - <br />A Insurer <br />----- <br />work Comp # l �- ? - <br />TICC Technician's . n Number <br />Expiration Date <br />R JCC InstalWs Certification Number <br />Expiration Date <br />Tank ID # <br />Tank Size Chemicals Stored <br />CurrentlylPreviousty <br />flame UST Installed <br />T <br />A <br />u <br />K <br />P` UApproved/L Rpproved withconditions UDisapproved <br />L (See Aitachnient VM Conditions) <br />A <br />N Plan Reviewers Name aDate 0-4-0K— 1 0 <br />APPIJCAO 4L IST PEW]OW.AL-14PRtc II -As. vurru cew. 2 di JaUX CODUTY nRPNP, ��.,<gAIE) ; nea).1 . AND.REGLAAPONS:OF SA i <br />JOACIM COLONTY, EMWIRONMENTAL }� LTH �PARTAtEhIT. 64it LICBJSED AGENTS SIGNATURE CH;ii THE FOLl.C7 A4G 'I CEATI THAT IN <br />THE PEIV:C MANGE OF TIME WORK FOR VMM THIS PERMIT IS BMW, I SWILL NOT EMPLOY ANY PERSON W SUCH A MANNER ASTO BECOME SUBJECT TD <br />WORKS?S COMfPENSA LAWS OF CAL FORNIA' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE C ERT FIES THE FOLLOW9413-. 'I CITIFY <br />THAT IN TFE OF THE WORK FOR WHIC FI THIS PERMIT IS ISSN. t SWILL EMIPLOY PER90t�iS SUBJECT TO WORKERS COMPENSATION LAWNS <br />CF CALIFORNIA' <br />AnDfi ar�Sfarr�ue .C, h" 'll 'Cf Zi Ik T -a. -7/-116 <br />indicate the responsible party to be billed for additional Bit) staff fire 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 admowledge this <br />respon for the bittinAby <br />ature and datebelow.�6 l'tn? <br />EH23DO38 (revised 8/8106) <br />1 <br />