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L_ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQM COUNTY <br /> L 600 Fast Mala Street,Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 <br /> L APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TM PERIAT ExPk M IIOOAY3"Win THEAPPROVAL OA7E.>AIDiCATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT'o PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F WA See# Project Contact$Telephone# A I Ze h,r, (U)19-42,-2400 <br /> A <br /> Fad0ty Name /F74-T Fiat qi u x Rhone# <br /> L � Address 345 SE. <br /> I Gass stmt �.1/1� 5L. <br /> Y ownwAv"tor C Co. 4va Ttr 4CW-4A Phone# ;L 1+- 4(d¢ Z.554 <br /> n Contractor Name 7BD Rhone# <br /> N <br /> r CantradorAddress CA LIC# Class <br /> LA Insurer Work Comp# <br /> T ICC TedmldaWs Name Expiration Date <br /> R ICC Irlatakes Name Expiration Date <br /> 6- Tank system work area Tank Size Chernicais Stored Currently Date UST <br /> a..m Ophg Nseo.Qr ft*dsbdo.WC Irl,era Installed <br /> T <br /> A <br /> N <br /> K <br /> C <br /> L <br /> I <br /> LP ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> i <br /> N Pian Reviewers Name Date <br /> L <br /> APPLICAMMIST PERFOW ALL WORK N ACCOimANCE WFM SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,ANO RULES AND REGULATIONS OF SAN <br /> JOAN"COUNW,9 VNO1 WffAL HEALTH DEPARTMENT.OWNEIR OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY THAT rN <br /> f THE P8WORIMNCE OF THE WORK FOR WNCH THIS PERMIT 13,ISSUED.I SHALL NOT EMPLOY ANY PERSON N S"A MANNER AS TO BECOME SLIBJECr <br /> T1D VrOR96n COMPENSATION LAM OF GMJFORIMA' CONTRACTORS WRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY <br /> L THAT N THE PERFORMANCE OF!HQ WCEIEFOR WHICH THIS PER&MT IS ISSUED.I SWU.L EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALNPDW MA.' p <br /> ., Ttre I Dam 10--or-61 <br /> BILLING INFORMATION: <br /> L <br /> in6xmft to responsible party to be tilled for additional.EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated bebw is different than the permit applicant, e.g. properly owner, the parry must acknowledge this <br /> responsi6iNty for the billing by nature and date below. <br /> Ir NAME iL��5 &OU*k Sian ---�- Pj�'1 _ PI•IoNE# �- 74S-1W <br /> LADDRESS It 31 IJ. c 91 A)- "12w,41CA 9 9S <br /> SIGNATURE DATE <br /> %%Ol, EH230039{-WsW 020Mt <br /> r.. <br />