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-- -- tVfR4NN ENTALHEALTH EYE PARTIIAENT-- <br /> SAN JOAQUIN COUNTY <br /> 304 Fast 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 /> DM PERMIT DCPIRM 90 DAYS FROM THE APPKMAL DATE INDICATE PERMIT TYPE 9ELCW <br /> ANK RETROFIT UPIPING REPMURETRORT i 6iC REPA1R40 RORT <br /> ! EPA SiieProject Qmtacl&Telephone�` f -63 <br /> A - - <br /> C Facility Flame Phone# <br /> L <br /> Add 3 <br /> I C=;s Street <br /> T <br /> y Owner/Operator Phone# <br /> a <br /> Contract,Name Phone# <br /> N Contractor dress CA Lac# <br /> T <br /> A Insurer work Comp# <br /> r <br /> TICC Tec"rreirsan's Certification Number Expa-ation Date <br /> ICC lnstalls�s Gertifiration Ntarlber Expiration Data <br /> Tank 1D# Tank Size ChemicaEs Stored CuDale UST lrlstatted <br /> T <br /> A <br /> w <br /> K <br /> P LIApproved ,-Approved with conditions LIDisapproved <br /> L (See Attaint watt►Conditions) <br /> A 6 N Plan R4Mewers Name. ® Date 6 L 11 <br /> T - <br /> APRICAtO MLLST 1?EWCIRU.ALL MARC +L UA�ATMSAN Y] C1fl!JCMiN7Y 0RaMNC S..-SCAFEtAlo 5:AN[a gIES AhD_R�S,OE SAN <br /> JDAC I M COLROY,ENVIROWENTAL 1 EALTH TMO+Ir_pM,1ER CR LCBISED AGENTS SIGIVARAZE CBTTIFIES THE FOI..s_OWN3: 'I CERTIFY TMT IN <br /> THE FIBZFIMMANCEOF THE WORK FCR WH1C H TILS PERMIT t5 ISSU T1,I Si-J NC3T EMF7AY ANY PERSON IN SUCI-t A MAN ER AS TO BECdME SLOB.IECT TO <br /> VVORXER'S LX•JMPENSAWN LAWS OF CAL1FOFmf1A_" IXN!"RAGTCOS FiERM OR NTRACTM SIGNATURE CE TrWIES THE FC LLONJ 4a "I CERTIFY <br /> THAT IN T7 E OF <br /> THE WOW FOR WIi1CH TI <br /> IUS PERMFT IS MWO I"LL EMPLOY PERSUZ SU&EGTTO VJDWEFZS Ci.7LFEWATION LAWS <br /> CF(;ALIFFORMA` <br /> � T !j„ NF1 <br /> F sN&A Tice ( i, d . � <br /> BILL INGjI FORMADON: <br /> Indicate the responsible party to be billed for additional EHD start rule expended beyond permit payment coverage per tank_ If <br /> the party designated below is different ffian the permit appr—ite.g. property owner, the party mast acknowledge this <br /> respond ify for the bitting signature and hats below. <br /> t�fRtl E _�� �/1 P �UJI i ll PHdNE# <br /> ADDRESS <br /> SIGNATURE <br /> EH2-IM38(revrsed 81t DS) <br /> 1 <br />