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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 /> THIS PERMIT EXPIRES 5e BAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE AL <br /> IIELO <br /> UTANK RMORT UPIPING REPAF/RETROFIT L1=REPAPiREIRDFIT <br /> F EPA Site# Project Contact&Telephone# <br /> A FacOily Name Phone# <br /> c <br /> I Address L� <br /> L <br /> I Cross Street <br /> T <br /> Y Ownec0perator Phone# <br /> Co Contractor Name 7 Phone# <br /> N contract) CA tic# j class L <br /> R Insurer Work Comp# )b5 -o <br /> A <br /> T ICC T 's C.ertifxation Number �a�fat <br /> R ICC Installers Certification Number E)Twabon Dam <br /> Chemicals Stoned Date DST 4sfailed <br /> Tank ID# Tank Size Crrenty/PteViorsly <br /> T <br /> A <br /> Y <br /> K <br /> p L Approved Bpprured viab conditions - UDisapproved <br /> L (See Attachwnt With CordBions) <br /> N Plan Reviewers Name /rVWYV Dam (5�- v-7 <br /> APPLICANT MUST PQ2FMM ALL xrla(eQ.A�aeCF-MMSANJOACLIUCO NTY.ORO� NCES.STATEL".C&nen OI AMRE;t• =NS OF SMI <br /> fY <br /> JDAOM OOIM .ENVIRONMENTAL HEALTH IDEPARTMENT.OWNER OR LICENSED AGE NCS SGMATU RE CERTIFIES THE FOLLOVAIG: 'I CERTIFY THAT IN <br /> THE PERFORLW CE OF THE WCRK FCRVM'ICH THIS PERWT IS 6SDED 1 SHWLNOT ELFUN ANY PERSCN IN SUCH A WVdB=ASTO BECOME SLELEcT TO <br /> WORIB2'S COMPENSATION LAWS OF GILIFCR� OONTRA=RS RRNG OR SUEIDONTRACTiNG SGNATLIRE CERTF1ES DE FCLLOV&Cd 'I CERDFY <br /> THAT LATHE OF THE WCRK F0RV"a-1TWS PERMR t5 IRAD.I%1ALLEYPLOY FERSCHS SUgECrTOWCFMRS COYPENSATON LAWS <br /> CF CALIFORNA' <br /> APpScmtST9>a4re n CTele :G <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 designated below is different than the permit appfroM, e.g. property owner. the Parry must adMDWledge this <br /> responsd��ypp for the bdfigg by signature a�date below. <br /> NAMF�(il� ZL � /6"1 TITLE , ONEyoui <br /> ADDRESS ES .. <br /> SIGNATURE f <br /> EH230038(revised SIMM) <br /> 1 <br />