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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQU 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 /> ''�II THB PSUBTEM ES 90 DAYS FROM THEAPRtOVAL DATE MCATE P=—RW TYPE <br /> 'BEOK - <br /> L_fTANK RETROFIT UpIPING RenuF EmoFn L6oc REPARfloRDm <br /> F EPA Site# Pmjed Utad&Telephone# <br /> C Faclity Name y Phone# Z1 <br /> � <br /> Address <br /> -� <br /> I Cross sheet <br /> T /r G <br /> Y owrwAlperator �! Phone# c O <br /> C <br /> Corrtrador Name W t c n Phone#. <br /> N ConlraciarAddress Z CA tic# W Class - <br /> r <br /> R Irrs,»er r p .. work Comp# Q <br /> A I �' <br /> TICC <br /> T Technician's Cerffk=fon Number ErRkation Date <br /> O ICC kistallsrs Ceracation Nurrlber E,#aBon Data <br /> R <br /> Tank ID.# _. -.. Tank Sim -_ Chemicals Shred Dab UST lrstalted -- <br /> CunenLylPnviolsly _- <br /> T <br /> A <br /> Y <br /> K <br /> PLPI,, <br /> . ... Lkppmved �mred with conditions Lbmappmved <br /> L (See Attad=ntWdh Conditions) <br /> A /q/� �(q G <br /> NReviewers Name /r'I�w� �U(A�-A ") Dale � �L14¢acro..v .fE�[aC teCR sncl.C]of1a1G4WY.CRM�"•.•'«..sAiE{Junsinenali s. f G19A$ow,SOF SnM <br /> - ..._... neo <br /> JaU L.1N aX*BY,BNORaAJOUAL WALTH nS*RTNEW.OMER OR LIB-LSE)AGENM MSP ATIRE Cgnfr=S THE Fa1DV&&:;: 1 CSrIFY THAT IN <br /> TI$P8W:0RMANCECFTfE WOW FCRV".H THIS FSnQrIS=JED I9FNLNOTEMPLM ANY PERSM W SUCH A MAH AS70MODWWIECTTO <br /> WORKERS CCWBGATM LAWS OF C&FUMA:' m ffR-4CT6is VIRMOR 9A C0WRACrM SRGMMJW CBMRES THE FOUO1VPIri -1 CSMFY <br /> -THATJN3E.FAWORMANCE a=THE VCW FOR V& CH THS PBUT IS WLE) tSHALLEURDYPStSOWS1B.ELTTOVYDWMZSCOLWENSATONVV%S <br /> AppGorisSlgehae -t)l ) LJ� L1. - U� <br /> Tdfe&LtOTa�b Dah- � <br /> BIWNG RMATION: <br /> Indicate the responsible party to be billed for additional EHD staff line expended beyond permit payment coverage per tank If <br /> the party designated below )s different than the permit applicant e.g. property owner. the party must adawwledge this <br /> responsbFrly for the billng jby signahae and date below. <br /> NAME CT.I iL,IT1 ( LnIyck, --, TITLE PHONES <br /> �l�iili�`�I�ir� <br /> SIGNATURE - 4 1 1 1 1 I <br /> EMM38(revised 81&06) <br /> 1 <br />