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May. 28. 2008 1 :23PM EsTFQ EXPRESS STOCKTON' No. 8862 P 2,,-Ya <br /> ■f <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 Rest Win Street,Stockton,California 95202 <br /> Tetaphonel (209)468.3420 Rax; (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THTU1r ES,ae DAYS FROMTHO APPROVAL DAT■, INDtCATEPERMITTYPseELowA I <br /> tesla <br /> r, SNETROPIT IPIPING'tUI+AIPA,ETPOrIT IJUOC REPNRrt+ETAOPIr 11COLD eTAJlTM:VR UPGRADE <br /> ATT _ Project C°�rMal et 8 TWOphOne >Y <br /> "'a!- <br /> v MAlnf � �, .•�•cf- _.� G Mhone p <br /> 9ueel <br /> �_ <br /> dopdrs!Cr xt ��- .� <br /> CkH Name <br /> _ _.� Sr<�rSrrPCi,Y� . Phone# <br /> clorAddresp �� CALicr! �p 2.�. its Cyd er <br /> h,aureT _,�T�N.N_I� _ WOrlt Comp ri�jZ� <br /> ° ICC Txhnidan's CerllNcallOn Number <br /> T _ Expiradon Date <br /> D 1CC Inelaller'a CenHlcatbn Number -� <br /> FA (,,.11� Explrpnan Date/�grChemlcels 91Dredank 10 q Tank size Dela UST Inetased <br /> CurrsneylPreLNtlyIN <br /> P rlAppro"ap pproved W1th Conditions []Disapproved <br /> ' A (8ea Altechmenl With COrdltbna) <br /> N Plan Reviewers Nomq-61 v. Date_• 6(1Z/o d <br /> APPLICANT MUSTPERFORM ALL W ACCORDANCE WN SAN JOAOVIN COUNrY ORDINANCES,ATATE LAWS,AND RAES AND R=OVIATIONa OF SAN i <br /> .gAOVW dOUHTY,ANVs1pNhY:'N A MEALTN OEPARiMENT,OWNER OR LICENSED AGENT?BIGNATUAE CEM1TIFIeS rMe rOILCAYWO! 'I Cef7rIPY THArN <br /> THE PERPORMANCE OF T T A PERMIT IS ISSUED,I ANALL NOT EMPLOY ANY PERSON IN SUCH A WHINER AS TO UCOMD SUaJECT TO <br /> WORKER'S COMPUNSAn LA Y�a CALIFOANIA�' On'S MMINO OR SUBCONTRACTING SIONATURU CIRTIFIES THE FOLLOWWO; ^I CERTIFY <br /> TWAT IN THE PF MAN 1N OAK FOR WHICH THIS p 7 IS ISSUED,I SHALL EMPLOY pAMeONa SUaJICT rD WORKERS CDMPENepnON LAWS <br /> OP GLNpRNM <br /> APP!Cerea 9YLi0ilYla ,' TM4 DAIe ZS 1 <br /> SING IN OR AT <br /> Indlcale the responsible party to be hllad for addllbrlal EHD staff lime expanded beyond Dermll paymenl COverage gQr lank, li <br /> the party doelghaled DWow is 0erenl than Rla permll applicant, e.g, propedy owner, the party musl acknowledge Ihb <br /> respomIdAIIly for Iha bllllno by Signature and date below. / <br /> NANIF /f{ O!11; ,TITf F,�_��•�M'�!/� r'e+�yf�p110NF,a�/F ,. <br /> � a.,.� Z-// ,�_ �C75aT.r*r��.TsDc1, J�.ryO� <br /> SIGNATURE <br /> 1 <br />