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EN, ROi\FI�E��` �f EALI- EPA <br />f(10 East Main Street; Stockton, Cafifomia 95202 <br />Tlvi� hone 209 APR 3 0 2015 <br />P { ) 468-3420' Fax -(209)683433. <br />_ <br />APPUCATION FOR UNDERGROUND STORAGE TAN RQNMENTAL-- <br />RTSEA <br />-- �NVI <br />RETR@FI7` OR -PIPING REPAIR -PERMIT <br />,r-. ,TSO nr_011'OT4pr�!'T' . <br />TFUS�EftM'!T EXPIRE5180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW: ' <br />O,�IANlt_RETROFIT ` ❑ PiPlNG REPAW ETROFIT D UDC-REPAIR/RETROFIT 0 COLD START/EVii UPGRADE <br />.. Pro*t.Corltact.&Telephone#._ ..IV <br />. , <br />c . <br />I FieiJty Name <br />L <br />--Moress <br />4 wui y .. .. ., <br />T. cro" Street <br />Y. Otivrlw/Operator <br />o Contractor Name �L Phone # <br />N qI -Ci <br />T COCitrdcf4r%iddr83S' JTCQ4�a CFS• �'S�(,'S.. CA LIc # (�1,1ClCD Ctass { <br />R. <br />A . tiL�UiQr 1 Work Comp #- <br />T ICC TechniciaWs Name Fx iratloTI Date <br />p <br />._. R ..ICC1n.,5rWi fs-game <br />EKpMon Date <br />Tank s*em work P%87a �da,�a�,a eta) Tank Size CherWcais Stared Currently Date UST <br />Installed <br />T <br />-A — <br />P ❑•Approved Approved with conditions ❑ .Disapproved <br />N. <br />__—_----•--_.—�SeeAttadW6it-WitlZ-Condi tw) -- __ ._ . _ .. _._...... .... _._ ... <br />Pian Reviewers NameC\V� Gly V a Date 5' S'21D k5 <br />APPUCANTMUST-PERFORM ALL --WORK-IN ACCORDANCE •WITH:SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN' <br />JOAQLIIN,COUNW- ENVIROAMENTAL•HEALTH'DEPARTMENT. OWNER OR MENSED AGENTS SIGNATURE, camms THE FOLLOWING' _'I CERTIFY THAT IN. <br />iNE:PERFDRMAAIC,FOPfIIeVVi)RKFpRWHICH:tHISPERtAITlSr3SUED.ISHAN NOT EMPJ..QYANypETtclS2itIL4.x�.UCHB.MAdNELi.A$:T08ECOMESU9IECTTO <br />WO_RKER5"COM7PENSWTIOWLAWS OFC�it.IFORRIA. tT(5N1MCY�`R§.HIRtNG.�R SUBCONTRACTING.:SIGNATURE-CERTIFIES THE FOLLOWING I CERTIFY <br />' <br />THXf NV THE PERFORMANGEOFTHE WORK FOR N(f{ H THISPE�iMii IS ISSUED I _ jALL.EMPLQypERSpK$: UBJCCr.TD:YffARI RS OMPEDIsanbN <br />- . _•. = <br />SILLING INFORMATION: <br />_._tndkate4he-responsible.party_to-beybiiled4br-addittonat-SMD-s#af time ex�endett:f?eygnli parmitpa_yr> n) gZyerage:perYank tt ... <br />rIJT fLcbely s' r ere`dr tfiaittie pertralt :aj3plicarit, a g.uoPertY-awrter, the pa must acknowledge this <br />_r'esponsbllky f r the blilin9.by_signafureand <br />NAME 1ZY�.i`: I �..�C�� �TfR:E l�ii pRrStt4fiTiVG - PHONE1l�I <br />- SIGNATURE—DATE <br />EF12&OQ38 (leyised <br />2 <br />