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h <br /> SAN JOAQUN COUNTY <br /> 304 East WeherAvenne,Third Floor,Stockton,CafiForn"95202 <br /> Telephone:(209)468-3428 Fax:(209)45 3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> t T'sPF EXL')RFS 90 DAYS <br /> E-FRW THE APrRWAL DATIAr GATE Pamrr TYPE t <br /> rr BELa <br /> UTANK PEEMOF7L <br /> T JPE'ING RFT ARMFTRORT LJtIpC i2cParRlrici'tUF T <br /> F FPA 5i <br /> A Pm sect Cantac't&Telcohone f <br /> C Facr7ily Name 1phone# <br /> t Address <br /> f <br /> L Add <br /> I Cross Street 9 <br /> T <br /> 1' t)wnerl4pet'atof � Phone� + ,, <br /> CorWac br Name l v� <br /> Ca Phone 0 <br /> N cont -ess 1 11 <br /> _ T CA tJi`$ <br /> Cess (yv <br /> � � <br /> A Qtllp C <br /> frssrsiWork <br /> fir` ^�^ <br /> � C)C fGG T-'vri�an'S <br /> T Certifigr6on Ncuzrber <br /> o (.s�, fation Data <br /> R 'CC kMtIWs CeTffKMEOn Nr <br /> Tank 9)# Tank Size Chemicals Stcued i]a�UST Ira l d <br /> CttrrenfEy/Preyioutly <br /> T a7 <br /> A <br /> K <br /> P Lkpp oved roved with cordifons LJDSsappmved <br /> A (see ch=nt With conditions) t <br /> Plan Reviewers Name _ <br /> bate <br /> ArPiJC1�f�1dL15TFpg�1unn AM <br /> ata _ <br /> F714CY1W Cx]f RfTY,Ef N6iCit�dt33TAL FSU TrI 1"C�ttLlT1C�.. _. _..a.. -._ _ Y c E1�1erc� r <br /> owrt�ax Lrcep Ac ,rrs stGa wTLrRE I,,,Trs`FixLDIr1H>u cst�>Fr trier tN <br /> Tim OF Trl=WOW FOR Vb H}i 7i!ZS�r2kHT lS SSL },r 9{AiJ_NOT BAPLOY ANY 1 IN aJ04 A UN+C�B2 AS TO E ME CTC] <br /> VV S CO"Fe4 IC 1 LAVIIS QF CAL�LA_- C7lWWZTLFtS MM OR aWONTRAC �-SUA URE=MES THE FCXr� `I C�lrY <br /> THAT JN THE PSW-OF2IId�OF THE VYOFM FOR MJK:2 t TICS PcRltrr r5 t�.�CH7,r SrdAr L E#dr^LOrt F gJg�GT TO tiY � <br /> OFCAL .ZXZNM' C 6ATtON LAAS <br /> Amts Sir�safue � TdiP�� `^-""-� pets <br /> 31LLING INI=ORMADON: <br /> Indicate the resPonsible Party to he baled for additional IIID staff tine expended beyond permit payment Covera Per tank- If <br /> the party designated below is drfFerent than the Permit fica <br /> appnl, e.g. pmPeth <br /> rty awmer, e .party must aclmawledge this <br /> respansib& for ifi-hitting by s' nature and dam below. <br /> f"E � Jl � udONE t V3 <br /> E <br /> AMR <br /> S <br /> SIGMTME U��= <br /> 8323oQ38(mvisect&W5) <br /> 1 <br />