Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3410 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMrT EXPIRES so DAYS FROM THE APPROVAL DATE RdXCATE PERUFT TYPE BELOW <br />e BILL] 114 t MATT - <br />indicate the responsible party to be baled for additional END staff fine expended beyond permit payment coverage per tank- if <br />the party designated below is &ferent than the permit applicant, e.g. property owner. the Party must aclawwWge this <br />upon =thrmgg and date below_ <br />KIAU d TLE PHONE t / <br />k. <br />ER23DO38 (revised 81=6) <br />1 <br />,/if.Z <br />VJTANK Fit I KUt1 l •••' • ••_• •�.•. •� ....." <br />F <br />EPA Site # Project ntact & Telephone # <br />A <br />Facility Name <br />Phone # <br />Address <br />TCrass <br />Street <br />Y <br />owner/Operator Phone # <br />C <br /># �� <br />o <br />Contractor Nameo <br />ContraCtor # � Class �7 <br />T <br />R <br />Cep # <br />InsurertiltQilC <br />A <br />TICC <br />Tedvmit� n's Certification Number <br />.Date . <br />R <br />1CC lnsialWs Cerff-ation Nrsnber <br />Eviration Bats <br />Tank D# <br />Tank Size chemicals Stored <br />Curiently/Previously <br />Dai- UST Installed <br />T <br />A <br />w <br />K <br />2UDisnappmved <br />L-APPro ved ws8t conditions <br />L <br />(�AftachientWdi Conditions) <br />A <br />Dati� <br />N <br />Plan Reviewers Name — <br />AKP,ETFQBLN-qp yDPiL ,OAqp(WI,hCS ,,TATE AKRLL ASB-R[DrA .OFSAN <br />SKSdATmJRE CffiilFiES THE FOtlCIABrG "! CERTIFY THAT W <br />JOACL/d CCLIIYEVNMETAL HEALTH CEPARirETTOM4E8OR LiCDtSED AGENCS <br />tS rSStIED, t SKALL NOT EMPLOY ANY PERSON W SUCH A MANNER ASTO AMIE 5 ��TO <br />THE PERFORM WJGE OF FCR VW4K;H THtS PERMIT <br />ORKERS CpMPgNSA OF C&Waa tk" CONTRACTORS HRWOR SLB0d RAGING SIGNATURE CEF?TWIES THE iOLLOW&IG= <br />VN; <br />PETtSCKS 9LIB.ECT TTOVYORKSiSCCOENMPSATIONLAMESOF <br />THAT- pit THE THE waRK FORV** -t THIS PERM'r is m7LriEMPLOY <br />CALIFORf�RA'I� l <br />e BILL] 114 t MATT - <br />indicate the responsible party to be baled for additional END staff fine expended beyond permit payment coverage per tank- if <br />the party designated below is &ferent than the permit applicant, e.g. property owner. the Party must aclawwWge this <br />upon =thrmgg and date below_ <br />KIAU d TLE PHONE t / <br />k. <br />ER23DO38 (revised 81=6) <br />1 <br />,/if.Z <br />