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I <br /> ENVIRONMENTAL,. 'F}aEP_ARTMENT X <br /> SAN JOAQUINAGOUNTY <br /> ::_.BOO East Main.Street, Stockton, California 95202, <br /> Telephone: (209)`468-3420 Fax: (209) 468-34Y2i-- __: <br /> RR-ICATI©N FQRUNPgRGROUNP--$TORAGE TANK iz -- --- <br /> Q TRIP -T IS'REPAIR PERMIT <br /> BAY.$•F14AAI`THE"ApPRG4Yfla 9f741fiA'fE PERMIT TYPE aEL04Vt <br /> 0 TANK.RETROFIT 0 PIPING kEPAIR)RETROFIT O UDCREPAIRIRETItORT. ❑COLD 3TARt/EVR UPGRADE <br /> A _FPA Sita#__ _ Protect Contact&Telephoge# y <br /> w SaDilityName f Phone# - <br /> Address <br /> ..._... ._ .1.._. _so _ - <br /> . .. TT.-r0¢s Sheet-- -;- .... F. <br /> Y Own@r/Operator - . . Phone <br /> _. .. . C `CarifibUbr;Natne _ ' <br /> D <br /> Phone# <br /> N .:Cont DtorA,Wress <br /> T G�ALia'0 Class <br /> R Insurer <br /> Work Comp# <br /> T ICC Tisch nician`s Name <br /> Expiration Date:... <br /> ICC Installer's Narr� - _ <br /> ... . . -•Tank systkm�workareft- <br /> Tahk Size' Cfiemicals$toned GLrrefftl <br /> ps.erPialneeumF,eih.¢aelxmruod,rr�,,?m.J'. Y. . . ... <br /> Install ad <br /> T - <br /> C .. - <br /> ❑ Approved- pproved with conditions - ❑ Disapproved <br /> (Se Attachment With Conditions) <br /> 11 N <br /> Plan Reviewers Name Gate_ <br /> PPLICANT:MUST PERFppR� M PLt WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AN RULES AND REDUI�TyONS SAN <br /> JDAgUIN.;COUNTY ENVIRONMENJT. HEALTH DEPARTMENT OWNER OR LICENSED:AGENT$SIGNATURFCERTIFI�.S THE FOLLOWING I CERTIFY AT IN <br /> WOR NOR- <br /> pa <br /> R�W(�MIQQ�H Tyyls pe NIT l§i &t EivD,I rtiI.�N4T, 1P1 P N1 t sht�sgf�lt Uy Sl1c�i A t�lsk]W �j1 14 fl 7ftE SUHJt STT9 <br /> : � -t;ALTFDhNIA CO jRAOjORS NIRINObRSUSCQNTRACTIN0818NATU��O�RTIFI�;;„ FOLLQlyINq "1,CERTIFY <br /> •A�-INXNF-P'ERl°IJHIdANDe bF Tt-IEiN014M�Oh WHICH�tsPsRTAIt I�1S�ttED'�$F{�L�K1P��'1 J'E:Rh�(J,iSUSJE.d77Q WORKER'SFDMPENSATIQN LAy�4. � -_ <br /> "�^_'^".T"'_""" - ';. +Y----•»-�IiYstcll.Y,atnlrlL..1dW���J,�u+�..:+-.,.0-. ri."-. _ - <br /> Irtdlaata-tlia res Ibl R tD bB t5il permit paymDn�� <br /> e pay esgnate 'be ow Is dHferent than the penn(t applicant @,g_pfQpe*. owner, the PaNY must aDkfIDWladge this <br /> rasponslbllityfor theblllingbysipnature.anddel e +1 - <br /> �5cm�9�i'VP;I <br /> PHONE it <br /> AbOTtEBS (��r�It , .caa <br /> .:.. SIGNATUt2E— Iia-aL�L1A.10=w—.�� DATEE.._1�1 <br /> _• l I <br /> r, i <br />