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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN 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 TYPEY1t <br />BELO <br />UTANK RMORT ' <br />PIPING REPAMZEMOFIT i 6c REPAIR/RETROFIT <br />F <br />I EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility Name r <br />,�, '� Phone # <br />L <br />Address 1 <br />s,< <br />ICross <br />Street <br />T <br />Y <br />Owner/Operator tj) <br />Phone # ,,�'i — <br />oCont <br />-actor Name �i i7 :L� <br />Phone #�j <br />N <br />TContracbrAddress <br />-" <br />t. a Cc�cxF rz �r" CA Lc #Q Mass fill, <br />R <br />A <br />Insider <br />Work comp #(. 0 - 12 <br />TICC <br />Tedmician's Certification Number <br />Expiration Dalt;, _ c <br />R <br />!CC Irlsfaltes's Certification Number <br />Expiration Date <br />Tank !D # <br />Tank Size Chemicals Stored <br />Currently/Previously <br />Dale UST tnsta!{ed <br />T <br />A <br />N <br />K <br />P <br />[JApP <br />pploved vrlth conditions UDisapproved <br />L <br />$e� <br />( Attachment With Conditions) <br />A <br />N <br />I <br />Plan Reviewers Name <br />Jgg(JJM <br />` �I <br />Date <br />APPLICANT MUST PERIFORM AL.L.MAIORKLNL <br />JOACILM COtiMl , EIJVRONMENTAL HEALTH DEPARTMENT. <br />Sl16R _"COUNTY., REGIA /ITJOr�tS,C7F SAt3 <br />CV*ER OR LIC84SED AGENTS SIGNATURE CERTIFIES THE FOLLOVJM: 'I CERTIFY THAT IN <br />THE PIERFORMIANCE OF THE WOW FOR V"CH THIS <br />PERMIT IS ISSLIED I %IAL NOT EMPLOY ANY PUMON IN SUCH A MANNER ASTO BEODME SAI ECT TO <br />WIURKER'S COMPe"TION ums OF CALIFORNIA" <br />coNTRAcTowS FIRING OR SLECONTRACTING S*NgTURE CERTIFIES THE FOUDAIII K`. 'I CERTIFY <br />THAT IN THE PE RFCR#AANCE OF THE WOW FOR NHIC H THIS PERMIT IS MED I SNAL.L EMPLOY PERSONS SLIELECT TO VCW.EtS COMPENSATION LAWS <br />OF CALLIFORTllA' <br />APPS <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff tine expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit apprimiit, e.g. property owner, the party must acknowledge this <br />responsibility for the bang by signature and date below. <br />NAME fCj1 Tr i V I, fj,l rlt.0 LOY S TITLE PHONE # c�& l - &Y.51 <br />ADDRESS z2 3` - tk� Z' I,, C; "A. r r <° Co# <br />SIGMA <br />EH230038 (revised 8MM) <br />WA <br />