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_ENVIRONMENTAL E4aLTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3420 Faz: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT DARES 90 DAYS FROM THE APPROVAL DATE INDICATE PE Mr-rp BELOW <br />BELO <br />I ITANIC RFTWIPM I Imo= RFDA2M;=7Mr)RT /) L63C REPMR/REMMT <br />F <br />I EPA Site # Project Contact & Telephone # <br />A <br />Facility Name a l <br />Phone �3 <br />Ls <br />C%1(/L <br />I <br />T <br />treet <br />T <br />Y <br />Phone#-7 <br />cor <br />RSt'E- <br />Name / <br />PhoNor <br />T <br />CALic# Class <br />R <br />Work Comp #A <br />t:mkiian' <br />Certification Number <br />ExpirationDais ITR <br />R <br />taller's Cin Number <br />1 <br />Tank D # <br />Tank Size <br />Chemicals Stored <br />Currently/Pte*usly <br />Date UST hrstafied <br />T <br />A <br />K <br />roved vim cbnd'&ns LJDisappmved <br />ntVlfdh Conditions) <br />AtURpproved <br />iewers Name Date <br />APPLICA&rT lit t * F�CXt.A4L.L.M1OW MLArrr9RnAArr vurna 4u.Y]6Cx1C ICAIl81TY rf�IC�SS SFATE IYKS :At�Q81t€S. AbB tS::OF SAN <br />JOAOUW COL xny Ewi RoN ENTAL HEALTH --sPARTMBptr. am4M OR UC &4SED AGEQPS SM ATLAM C E RTIFlFS THE FOLLOYA43- 'i CERTIFY THAT IN <br />THE PERFTHE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL NOT EMPLOY ANY PERSON N SUCH A MANNER ASTO B800ME SUB.lEC,'r TO <br />y1R7RIfEt�!�Ar'LAVje OF CALIFOF A .' ODNFRACiC:YS HIRMOR SKMTLIRE CERTIFIES THE PDLLOVWOG: 9 CERTIFY <br />THAT tN TOF THE V OXW TQHI/S� PERMIT IS ISS M. I SHALL EMPLOY PRISONS 9U9 -ECT TO TIYV WEBS COMPENSATION LAWS <br />OF CAIX;0R1NW <br />�l.Y!% <br />�TNfe <br />SIWNG INFORMATION: <br />indicate the responsible party to be billed for additional EliD staff fine 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 adarowledge this <br />responsibRy for the billing by signature and date below. <br />NAME / Y TITLE ke 911a"ONE # 2M / 46 / -(43-75 <br />&23D= (revised 8►8/M <br />