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J,:1 06 2010 9: 07AMLASERJET FAX P• 3 <br /> 09Y D912009 NED 1t: 02 FAX 2094903733 SJC 6H0 »-- Stockton SaTV Still, Eq Cc 14009/Dou <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIMCOUNTY <br /> 600 float Main Street,Stockton,California 95202 <br /> Telephone;(209)468-3420 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> 7 PENMrTE% 191100 r)AY7rTHE APPROVAL DATE INDIOnTI EERMITT'IPI eeLOw� <br /> ❑ TANK RETROFIT Ldl P!f; NRG-RKE A Jf�(E��T)RCIO7FR ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRAAF. <br /> F EPA&110 Project Contact&Tt•Hepl,vrla R TAIPEI-.r &. I <br /> A FDcililY1"8nne tK fALI.I- "T'uSat�T <br /> Adn ass JSzFa 1 ins_ ' S*� cS ? C1�• _ <br /> do <br /> T Chose Street <br /> r !� <br /> Owns pent O ttM_ PMn�o M // 3 .L!r�.._ <br /> oContractor NAme �pa .S'.,r�. �,A_rn Plwnaa ZOQ.1 &,jj <br /> + ConHactdr Address - ST-. CA Uc M pq/OS ClassA"/ �R��i1jf <br /> A Insurer y/�y. Work Comp 1 r <br /> � . •ICC rier lclan's Name �,�� 1�lAJYEJV?rt>r� Expiration Onto <br /> °R ICC Insranees Name _ Expxetlon Dale 11I <br /> Tank system work oma - Date U51 <br /> a+.r oasw.,r.,1n..nwnu�.vpC la,1c Tank Size Chemicals Stared CLurenUy batsmen <br /> AY _ <br /> Fit L <br /> K _.._... <br /> P ❑ Approved Fe <br /> -lit dltlo ❑ Dr9eDprp�eU <br /> L - 19 AUaUWt y ) — - , <br /> L U <br /> N Plan Reviewers Name aLe-- <br /> APMICANT MUST PFAFORM ALL wCAK IN A OORO FITN 6 I JOAOUIN G"rzv CES,STAIE LAWS.AND RULES Iwo RM3UUTOR,DI'aAw <br /> JOApuN COLINTY,EWRONMFN Nf/d1N DEPARTMENT.OWNER OR LICENSED SIONATIx{e 4ATIFIE9 THE FOILCWiNG: 'I "'TIF'THAT w <br /> TIM PERFORMANCE F T E W FOR WHICN TNI$Pfil LS CBMD.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER Aa TO aEOOM!SUBACT <br /> 70,YORKERSC P IA• CONTRACTORS HIRWO OR SUBCONTRACTING 916NATURE CERTIFIES THE rOLLOWWO; "I CF.RTI4r <br /> MAT W iHF►ER PMA T .WORK FOR E PEAMIT IS IE7iUS014WJ1.EAVLOV PER90N9 aUSNECT'r0 WOnxEit'S COMeENSATKM LnSY' <br /> OF CN IFORNIA' <br /> ApP4ANA 9 MIS _ — Two <br /> IL ING IN ORMATION: <br /> IMNtdte the responalOM party to ue DBlod for addilmnal EFW Awtf Ilme 09COn000 DOyOnd PSMI payment COv911196 par lank. It <br /> Ine deny ormonsted udow Is different mon the pernl0 applldanl, 0,9. property Owner, the party must ABknrw,lvdgp man <br /> raaae O01y for the Nit Dy Flpnarurc and difla Deluw. � - _J� <br /> NAu611"- 9.. � _TITL Uw["YN� <br /> PHONE <br /> ADDRESS.��rs� GeNlT_�l eFl .�� 'me— y- . ...._...�__--...�..-._......_ <br /> SIONATURE SS..�/ - <br /> EH,130078 tents ROOF) <br />