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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 <br /> Telephone; (209) 468-3420 Fax. (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> TlcS PERMrr E%%RES 180 DAYS FROM".E APPROVAL QATE OCICATE PERWI TYPE U LFJN <br /> TANK RETROFIT -jREPAIRIR.ETROFCT ❑UDC REPAIRIRETROFIT A COLD STARTrEVR UPGRADE <br /> F EPA$ite M ProiTakphor ie IY p <br /> CFacility Marne 1Address <br /> IC(O"Street. <br /> T Pboft R [ <br /> Y Ownedpparalor - <br /> C <br /> Contractor Name s. PtWIe t3 - 7 — qRqA <br /> N Contractor Addross rr"}.a C CA t.,iF ai ZL <br /> Clan <br /> T <br /> R Insurer YJak Comp tT <br /> C ICC TedRNaian's Name S Expvi;tlrn Date S"_ /-z- 'CiU 1 <br /> pIG <br /> C InsWtler's Name j Expiration Date _ -. Ze <br /> Tank afsbBrn work ma, Tar*SU Chemicals Smred Currently Date UST <br /> q•v cora w+o W rr arrnr,tM!_Irj..Ic 1 Inslalle[1 <br /> T1 _ -.-- <br /> A <br /> N <br /> K <br /> P -. Approved wlCr Oormons Disapproved <br /> L / G/ men With Corrdaions} <br /> A <br /> N Plan Reviewers Nawl�— DBEs <br /> APPL(CANT NUST PERFGRM ALL W ACCOFDANCE wTH SAm ASAISWN COUNTY OMNANC€S. STATE LAWS,AND RIAES AND REGUUATIKM OF Sal <br /> MAOUIN COUNTY EliVa{Or1ME AL HEALTH DEPAATIL/ENT. OWNEN OR UCENSEO AGENTS WiNATLIRE CERTIFIES THE FOI LOtlMNG- '1 CERrrFY THAT IN <br /> TW pEW'ORLANCE OF THE WORT[FPR WHICH TwS PEFA&T 1516SUM.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MMiNER AS TO BECOME SMAEOT TO <br /> VVCAYJJM COAPENSATION LAWS OF CALFs9RTPA.` cONTRACTO" HMNO OR SUBCONTRACTING SIGrLATUM CERTIFIES THE FOLLDMND. 1 CERTWY <br /> THAT IN THE PE /O�F T1lE wCRN:FCR WHICH THIS PERMIT AS ISSUED.I S7iALL EMPLOY vER90frs SueJECT TO wORxETTS COMPENSATION LAWS <br /> of <br /> �4L' / Too r� Dru O <br /> f If <br /> BILLING INFORMATION: <br /> Indicate pre Lao patty f0 be tNtlad W addrooriat EHD staff titre exryerded GeyoM peRnt payment coverage per tank It <br /> the party oesapvm d below Is diPterent than the permit applidkM, e.g. property DvYner, the panty muat admowledge thio <br /> responsibility for the bftV by signature aro date below <br /> NAME—1")lk Y ,T{TLE^� j1`,, PFMJP7ER - ]G - �91 <br /> ADDRESS J.1—;.r„ .IrL:rs7 ham^ l«'�� <br /> SIGNATURE ��''�� T`—,F-f- -1�1—�p " <br /> EH23CL�331+�naJ <br />