Laserfiche WebLink
0 # <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQ"N COUNTY <br /> 304 East Weber Avenue,Third door,Stockton,California 45202 <br /> Telephone:(209)468-3410 Farr:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> a THIS PERMIT EXPIRES 90 DAYS FROM TIRE APPROVAL QATE INT)ICAITE PERMIT TYPE BELOAt <br /> UTANK RETROFIT UPIPING REPMRFTRORT U=REPAPAZE[` p T <br /> F EPA site# Prete Contact&Telephone# /— , /-3,3 <br /> G Facs�ity Name Phare# LfkGj,f' 77 Q <br /> I Address <br /> I Cross Street <br /> T <br /> Y- 0wr erA)peramr ` Phone 9fil <br /> C <br /> Coma Phone i <br /> Contrar , Co Class /D <br /> R Itts work Camp# J <br /> A <br /> C <br /> T iii;: Ca <br /> ICC TeExpiationon Number Expiation Date. <br /> R <br /> ICC krialiet's Cer"cation Nranber Expiration Data <br /> Chemirals Stored <br /> Tank 1[l# Tank Size Currenity�viously Date UST Irrstaled <br /> T <br /> A <br /> I u <br /> K <br /> P L-wPPm wd with conditions LJDL&v ved <br /> L (,See Attachment With Conditions) <br /> " Plan Reviewers Name pats 1 d L7b <br /> D <br /> AES MUST F_'ERFORWALLL WOW 1.M.9L CCMAWXWTHSAH JpiACai CMWIY. ial�S -<ZAT_f'—*ay AbI D FEES AflB_WaXATMS.C IF-%IW <br /> JOAa-NN COI MY.EW RDNME3TAL HEALTH DEPARTMEW.OWNER OR LICMED AGENTS SIGMTLJRE C81TIFI S THE FaLOM, 13+ 'I CERTIFY THAT IN <br /> THE PERFOMMANCE OFAIE WORK FOR V441Cd TM PERM r IS D'%ja),t S-NIL NOT EUPL OM ANY PERSON IN 5"A UAAC E3R ASTO BEMW SUB.ECT TO <br /> V4O 5 COWBCAbON LAWS OF cN-rFOWrllll' CSNTRAGTCR'S HIRING OR SLUC C TIRAC M SIGNATURE CERTIFIES THE FO LOM GV 9 C ERBFY <br /> THAT INT} OF THE vo,-w FM TPJS PUMIT IS MAD. %ALL.EN-LAY P W3.ECr TO WORKERS CX]MF'QI�.,ATKM LAWS <br /> OF CA J OPtIi[A' <br /> Appficaris 5graire Com/ If L l i� Te. I Ott /U CJ <br /> BIWNG t RMATION: <br /> Indicate the responsible party to be billed for additional EHL)staff tree expended beyond permit payment coweraye per tank- If <br /> the party designated below is different ton the permit apprKaA e.g. property owner. the .party must admawtedge this <br /> resportsbt the baring by s' nature and date below. <br /> Nar<+tTITLEIX, Ai lYE s <br /> I ,//CLI/9iT , <br /> SIGNATURE <br /> ER230038(revised MM) <br /> 1 <br />