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_N_ N <br /> ENVIRONMENTAL H-1 LTH DEPARTMENT <br /> SAN JOAQ"N 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 /> THIS PFRMfTE)"PES W GAY <br /> IS FROM <br /> L_ <br /> ROM THE APPROVAL nATE INDICATE PERMIT TYPE AC <br /> BRO <br /> LJ <br /> . LJTANK RETROFIT PFING REPARrRETROFrT k=REPm%TmfROHT <br /> F EPA Site# Project Cantad&Telephone# <br /> A FacLty Name . Y- Ph '# 3 <br /> � Adams 1 U d S Cqj** v Z-S CO3 LA <br /> TCross Street - <br /> Y Ox,000perator Phone# <br /> G Contractor Name Plane# <br /> 0 <br /> .Nr ContrafxirAddress a �7`i CA Lic# C�82�1..0 Class <br /> A Insurer 11� QYI.C.I., 'fJ , O QM _,CSti work Comp# 03 OQ Ll I�.. <br /> TIGC Tedmaan's Certification Nranber F�cabrt oaee 1 <br /> R fCC IrtstaWs Certification Number f"31 3% a lk Expiration Qat <br /> Tank m# Tank Sia Chemicals Stored Currendy/Ptevioasy gate UST ksta6ed <br /> T <br /> A <br /> u <br /> ' K <br /> P ur.pptoved mied%0*m CMUR60I5 uusappmvea <br /> Antwfnf Conditions) Il u� <br /> N Plan Reviewers Mame \ �V�W Date <br /> rrsur MUST FERFORWALL.ZCRIC_f�LA4 _+O+OT•+cera,y�9pfIDiLbletty.="-'••"'��.srATEl�1ws::nenBlaE$.aep.iic._fa.A7YT1s...OF 51W <br /> "CEM COUNTY.@NbiOldR�ITAI HEALTH D'PARTME1dr.OMfR CR LCBtSED AGENM SGNATIBE CHOIFIES THE FOLL(Wa a. '1 CEPn1FY THAT N <br /> TIEPERFORMANCEOF TWWCRK FORVWCH THUS PERWI-S BMW,I SfWLNUTE11PUNANYPEIMN N 9XH A MWER ASTO BECOME SLH6RTO <br /> VJOR10 s COMPENSA"N LAMS OF CALIF-0fa< CONFRACTORS HRMOR S BCONTRACING SMATURE CERTIFIES THE FCI1jOV&J 'I CERTIFY <br /> THAT N THE FERFOPUM110E CFTW NCRK FOR WtitW THIS PERMIT'IS MM.ISHAU-BWLOY PERSONS S1B.ECTTO MINERS CCUBSATiON LAWS <br /> CF CALSOFUCk' . <br /> ACPT Sre�. T��`U� L Cc cc) ire Li <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff fine expended beyond permit payment coverage per tank If <br /> the party desigmted below is different than the permit appfifaftt e.g. property owner. rhe party mast adarowledge this <br /> responsibility for the billing bycsgnature and daha'hetow. ' <br /> NAME v ` �jJa TMES2 t tj_ OC:o. lw al 4� 1 - l <br /> doADRESSaS- CT <br /> SIGNATURE L f` � Q <br /> V nib <br /> ,Q ' <br /> 1 <br />