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,i <br /> ENVIRONMENTAL WEALTH EPARTMEIJT <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 /> ' I THIS PERMrT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW <br /> UTANK RETROFTT UPPING REAL2/RETROFrr U(mc REPAIR/RETRORT <br /> FF ,EPA Site P ject tardact 8"Telephone 9 <br /> A <br /> C FacHity Name ( i Phone# _C <br /> t Address <br /> L l C' <br /> I Cross street <br /> T <br /> Y Orwner/Operator Phone II` <br /> C';) Contractor Name Phone#. <br /> L <br /> Lnlracbrlddre r' CA U-a1F <br /> Work Comp 9 7 _ Ga� U <br /> ICCan's n NR>trrbar _ B*aLon DaIR 320/ <br /> s Certification Number E-q*a5on Dat. <br /> Chemicals Stored <br /> Tank ID# Tank Size Currently/PreviDUSIy Date UST Installed <br /> T <br /> A <br /> w <br /> K <br /> p UApproved Lrkpproved with conditions UDisapproved <br /> L Lee Attachment Wrth Conditions) <br /> A <br /> LL� <br /> N Plan Reviewers Name �< < DatHBA/r �_ <br /> APPt1CAt�[71,auSrPERF0MALL,WDMCI!h _.... .._ _.. .._._. ..---. t] IDdAZJC S.. RIE nyftsi:AeQSf ES.ae[)i 7,IAl+TY7ASs;oF.SAN <br /> .I<7Aam COUNTY,8J RowiE JTAL H AL.TH--EPARTmEmr OWNER OR LICEIZED AGENM SIGUATURE THE FOLLOYR4 'I CS hT Y THAT IN <br /> THE P9W;ORW WCE OF THE WORK FOR V"M TM PERMrr 1S ISSN I SHALL NOr ehIF1JW ANY PERSM IN SUCH A MAN 1 R AS TO BELOW SLIBJ�T1D <br /> VJORKEFZ'S CXA1PI3tE;ATjakj LAVVS OF CAUFCRlUl' CONTRACTOR'S HIRM OR SISNATUlFRE C137TUIES THE FULLO ANN '1 CERTIFY <br /> THAT IN THE OF THE MW FOR NMICH THS I MMTT IS ISSUD.1 SHALL EMR C7Y F'l3250hFS S(.3 Cr TO►YORKERS C.OYPENSATiON LAWS <br /> GF CAUFCCA' <br /> pppSigre Tdte Owe <br /> BIWNG 1 RMATION: <br /> indicate the responsible party to be billed for additional EIiD staff fine expended beyond permit payment coverage per tank If <br /> the party noted below is ddferent tlsan the permit app—rd, e.g. property owner, fhe party must adkrowledge this <br /> respoltsi#I r the bOGrlg fry sia I1re d dates below. / <br /> NAME l TITLE I%C� /I E 9 41 ' 33 7 <br /> ADDRESS 7 <br /> SIGNATURE <br /> EH23DO38(revised W8M) <br /> 1 <br />