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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE 13ELOW <br /> UTANK RETROFIT UPIPING REPAR/RETROFTT L6DC REPAIR/REMOnT <br /> F EPA Site# Project C ntact&Telephane# � G <br /> A <br /> c rAd <br /> Name Qr } Phone# 14 7 <br /> L <br /> (' (� 1 Ut J C�. 2 <br /> reet <br /> �' perator Phone cS, _9 31 (o <br /> C Contractor Name �n� <br /> O Phone# <br /> N Contractor Address 1 r. tic# Class/� C l D— Az <br /> AT ) �J <br /> Insurer ' Work Comp# ! / 8' <br /> TICC Technician's Certification Number Expiration Dabs <br /> RICC Installer's Certification Number Expiration Date <br /> ls Stored <br /> Tank ID# Tank Size Cu�rreenntly Lmly Dale UST Installed <br /> T <br /> A <br /> N <br /> K <br /> P UApproved proved with conditions UDisappmved <br /> L (See chment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM.ALL IIL SAW Jak MCa)WY 09EX�.SrAIELAN A�iP Ea R AKa_REGIAATK7± CF SM1 <br /> "aur,;COUNTY,Ew ENTAL HEALTH cEPARTMENT.cw4ER OR LJCmsm AGwm SUTURE CERTIFIES THE FOLLOYIB�: 'I C87ftFY THAT IN <br /> THE PERFORMANCE OF THE Wl7RK FOR WHICH THIS PERMIT IS LSSL IED I SHAG_NOT EMPLOY ANY PERSON W&U A MANNER AS TO BECOME SLJB=TO <br /> WORKER'S COAPENSA LAWS OF CALIFORNL L' CONrRACfCf2'S HIRING OR S",JATURE CERTIFIES THE FOLLCNV1N : 9 CERTIFY <br /> T FLAT N THE PER OF THE WL>W FOR MCH THIS PERMfT S ISSl— L SFIALL EMPLLIY PERSONS SLELECT TO WORKERS COMPENSATION LAWS <br /> CF C/WFOWCAA' A. <br /> APPartsSgrati+e TEIe Q �`9 (/U <br /> BIW RMATION.- <br /> indicate the responsible party to be billed for additional EHD staff erne expended beyond permit payment coverage per tank If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must admowiedge this <br /> respo dity for the biking by signature and data'below. <br /> nFRNA Q.r'rl I TITLE e r PHONE# <br /> A IR' <br /> ADDRESS <br /> SIGNATURE <br /> EHt23DO38(revised WW) <br /> 1 <br />