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110/12/2006 14:48 2097440118 USA PAGE 01 <br /> 09.'': r.©v_!e A-1; 16 -101au5r•, E 1 . -.6F ,.,. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue.Third Floor,Stockton,California 95202 <br /> Telephone: (209) 468-3420 Fnz: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> inti PERMIT FJIPIAEG Ea DA:"S FROM THE APFROVA.DAt E, INDICATE Pe\MIT TYPE 6ELOw <br /> TANK At.1 A(;FIT SPIOINd R6PNWRE7ROFIT �VCC aFrAIR.'RE7FOr'• <br /> -------_ --�'_q-` �r✓rt� l-�l�_�T-•ufect_cenn<xtSY6deptwnat <br /> _— <br /> i' i <br /> , <br /> �; ; f aC:fit. N4sm- t•� Phortc 4 T�. �C C %3 3 <br /> ; Cross Street <br /> __—_rltlo ._...�- <br /> r �I�Owneerator U rr /1 SJ <br /> -�-._ . <br /> Ptic u�J - •C�c__ <br /> " I +.Dnt aOWr AOam$t P o• 13�r, 13 5 ,5}ockisn,U} CA be• 8 l l l Cross C<vl�Ddl/C61 AHP <br /> » <br /> A h insurer r1d _ 1 — LVOrk Comp b � (o <br /> i.!.. edlmiCian'a CartlNcaGon_NI,DIberQa13.�-a.1' Expiration Data3�n 7 <br /> I F CC InsWiti a Camfiwhon Number E !r*W Dole <br /> 'r--'--. --- - <br /> i �- S:,lamicals SFOrpy �! <br /> tank ID 0 Tank Slee u, aptly/PreviDusly Daor VST:nstafxd <br /> Aj <br /> ' --s;n:r5vec ll,aPfNo>.xtf vnth COnditona '_biwFrovac <br /> See Attaehmern`Nth(,n JAIDnat <br /> M i / 10 <br /> I F^ <br /> ! PIS!,f1aNA+wers Nsmt_--•O t ------- be[er•�l4_I <br /> j APPLICANT VVET PER•OPM AL:.A DAK IN ACCOROANCE WITH SAN JOADUIN cV�NTT ?RD;-4ANCF5,SWrt :AWc AND RULER ANO REGVAArOms Or$AN <br /> .:7AC,l:rti COUNTY. ENVIR0NMENTAI +4EA,TH UtWAAI ONT.DwhEP OR UGE W5E0 AdENT'S SIGNATURE CERTIA.RS THE •OU.OwINN 'Y CERTIFY THAT IN <br /> THE OF)HE W RK-,',IR WHICH T4)$PERMIT 15135 USC.1 VtA61,NCT 1IMPL13Y ANY PERSON tN SUGa A!FANNER AS T'D BECOME SUE/eCT TO <br /> WDNF%4'S CCMPENSATIOti LAWS OC ..a:.,IQRN:a.' CTNTRACTOR'6 MIRING ^F' SUP,CBNTRACTN6 SIV.ATL'R! !:tRTIF1tt2 'HL FCLI;'WNy '! CERTIFT <br /> THA'm• 'ME rERFORMANCE OP TNM'AtlRK:OR Wk ICH THIS PERM!"15 YSSVE5 &j&,EMPLO'•PeROONS$ViJ@:'TO wC:PKEP.'8 COMPFNbAim uW: <br /> +:aLr OHroA.' <br /> AD/ICIIiK sgnAlure r �...... (.lr`�� rlee c.0 <br /> BILLING INFORMA'flpN; <br /> IridrrAta the raspenslble party to be bliled /nr Odditional EHD stall t:ma eYpenaeD beyarM pannrc prymam covarrge per lana. ;r <br /> the Davy dastgnatad below Is dftterent than the Parma amficart -.y p'apemy Dwnar. the PTrty raft .CKnDMlatfw this <br /> raspors!biht tpr the b;Rp q by s�pnature and date baba <br /> PrlsU-�1,,,1, m l:_y-rp <br /> L.�l_�, ;w L-----TITI_Ef K�rT11 A1 . ��`�., PNONEa1=1 tl <br /> — -- " Paat•i1R Fax Note 7671 Dun- If CIF <br /> cu7rOC38ln.,sOa a/FVOG' To --rte.// <br /> n ro <br /> t S <br /> CoAmpt. c,�4 CA <br /> PNone PhoneO <br /> u <br /> M <br /> . <br /> Fax qs"f.�/]• -3`133 Foxe 8 -0,4,4 <br />