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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 /> THL3PIE RMT FRPIRF.5 I W DAYS FROM THEAPPRCJVAi CATE INDM TE PERWT TYPEMLOW <br /> C TANK RETROFIT U PIPING REPAIRMETROFIT 0 UDC REPAkWRETROFTT }(COLD STARTIEVR UPGRADE <br /> F EPA Site M Project COntaet&teleplone N <br /> A <br /> C FaaWy Name }Yl n . re kI Phone M t <br /> I A06 M <br /> I Cross Street <br /> T <br /> Y 0wrior;0perator 1136Phone x (' <br /> C <br /> D Contractor p"* <br /> T Contraadr Address �' frA w.» Lace Class <br /> R <br /> A Inguen Work Comp k <br /> T ICC Tocivvdan's Namej Exprabon Date -5 12—. 20 <br /> D ICC Installer's Name Exprabon Date <br /> R <br /> Tank system work area Tank Stip Cnemlrsfs Stored Currently Date UST <br /> o•.a Fina.�w♦+.r�a.a..m..we�R r I Inalalled <br /> T ? 7 S7-P Sw.n CJ C'G�fJ L�eM1 11 fi [ R :%" Y <br /> N <br /> K <br /> P Approved iF—"ApWaved with condsons OisapprOved <br /> L tSee Adact meet With Conditiom) <br /> A <br /> N Plan Renewers Name Data //— 1-2— <br /> ICJ•xT MJsr PERFORM ALL W A0001111IIiNC9 WIN SMI.10ACON COUNTY CIRDNLAM.ES.STATE LAWS.AND RULES AND REGULATkohiis OF SAN <br /> jopwN coow Y ENVIRONMENTAL W-PLTN OLWITMOIT.OVMER OR LICENSED AGENTS WNATVRE CERTIFrES THE FOLLOWNG i CERnFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR VeeCH TMS PEAMT IS ISSUED,i Swux NOT E.MKOY AW PERSON IN SLCN A WANNER AS TO BECOME SUfiECr TO <br /> vvoRKEprs CCAFEIr$AnCM LAWa OF CALIFORNIA' CONTRACTORS HIRING OR SUBCONTRACnNIG WRIArt.*f CERTIFIES THE FOLLOwiNO 'I CERTIFY <br /> TWAT N THE PERFCwNANCE OF TIE wORN FOR VARCH MS PERMT IS LSSLED,I SHALL F.AIPLOY PERSONS SUBJEOT TO WORKER'S COMPENSAT�10N LAWa <br /> OF CALIFORNIA' /I r. _ <br /> Ap�♦ I TAM I�l� J DLV <br /> j' BUING INFORMATION, <br /> IndwAs am responsible parry to be billed for additional EHD staff time expended beyond permit payment coverage per tark. If <br /> the parry designated below is dMerert :Tan the permit applicant. e g property ownw. the party must acknowledge this <br /> responsibility for the billing by sign tore and date below <br /> NAME .y A... . f LJ 9 � TITLE- �f P"iE a ?4 <br /> ADCREss <br /> r <br /> SIGNATURE DATE <br /> EH230MB OWW147mvi 1) <br /> 2 <br />