Laserfiche WebLink
SAN JOAQUIN COUNW <br /> 304 East Weber Avesue,Tkird Floor,Stockton,Caffornia 95202 <br /> Tdepbo (209)468-3420 Fax:(249)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TNS PERINTEXPRES 90 DAYS FROM THE APFW AL DATE MrATE PMff TYPE BE]nW <br /> LkA wmoFrr f)L6=mmmtErmw Lk=REPARNOTOFTF <br /> F EPA Site# j Project Carr1an1&Telephone# <br /> G lFacAlyName Phone 5 <br /> L Add , <br /> I c�Sty <br /> Y owned phone Q J <br /> C Contractor Name Pitons <br /> 0 <br /> T Corurarbr , . CA t�# t�� C� - <br /> Ainsurer Q�. Work Comp# <br /> C JCC TecJrnicxan's Nurrber EJ*atiion_Dain <br /> T <br /> R JCC s Date <br /> R <br /> Tank JQ# Tank Size Chernkals Stored Date UST hadalled <br /> CunendyfiNemusivT <br /> A <br /> s <br /> K <br /> P Vt�r cmd1liop vw <br /> L (See Immix Conditions) <br /> A f_p <br /> N Plan R Narnq Date <br /> Appj.,�ritt�sr __ ... . ._ ..._.... ...._. _. .._._ -!�!�crY. -- -..�._ �•!!t�J _... . �._..:�'sa+s <br /> JOAGXIMI CXXJ rY,ENVIRONMENTAL HEALTH DEPARTMENT.OV44E♦2 OR LXJBM3ED AGENTS THE Faiowsxk '!cERhFY THAT IN <br /> THE FSRFCPJAANCE OFTfEWORICFC)RYNi1CHTMFERWr6=JED.ISHAILNOTSPLDYANY PiRMUNINSUCH A ASTOBEOOWSUBJSCTTO <br /> LANG OF CAtff;0FVM' OONiRA=R'S HRMGOR SUaDONTRAchNG SM AATL6E CERTWES TFE FWINWOM 'a C ERTtFY <br /> THAT as THE <br /> ofTN <br /> CF TIE WORKWORKFaoR 1]OS PSi�UT IS{SSUQ)a t P6 SUBJECT TO WORKERS. TIDN fJgllfS <br /> igl ��L 1-5-LO <br /> ftxfi ate the party to be belied for additional END staff fine enmrided beyond permit payment cDveerage per tank. If <br /> the party designated bah is different than the peand a g. propedy owner, the party mast admawledge the <br /> the br&V byqgnature,and date-below. <br /> Amo lam- TTtLE Irr� PHONE# <br /> AI$lRlrSs { ( r <br /> SIGNAT L RE <br /> ( <br /> 1 <br />