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r ENVIRONMENTAL HEALTH DEPARTMENT <br />' SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95262 <br />Telephone: (209) 469-3420 Fax: (209) 46S-3433 <br />IF <br />A <br />C <br />I <br />L <br />I <br />T <br />y <br />C <br />D <br />N <br />T <br />R <br />A <br />C <br />T <br />O <br />R <br />T <br />A <br />M <br />K <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />>a�E <br />THISPErRUME*'IRcSSoDAYS FROM THE APZOVAL?ATEtrryC <br />psrmTvFCBELOW <br />UTANK Rc'TRor-u UPIPllJG P.EPAwRETRoeT UDC rRE AI�iRDFIT <br />EPA Site # Prejed Care at & TeJea :orw # <br />FacHity Name r-mr) Phone # %/n=AddM <br />Contractor Name <br />ContraclrAddres5 <br />Irr;uremr M )ny <br />ICC Tedrni=ian's Certification Number <br />ICC kts'alWs Ce on Nunber <br />- _ - - - . - . _ Tank ID # .. . _ _ I Tank Size _I - <br />Phone # <br />Phone # <br />CA Ltc # % <br />Work Comp # I t 0 <br />Expkation I?ata ` <br />Expia5on D to <br />chemicals Sbred i)ate-UST Installed.. <br />D riehtfylPrevvb iy - . - - - <br />--DsaPPmved <br />P Lkpp.o ed UApproved with =ffifions <br />L <br />A With (See Af:acimnt th Condifions) <br />N Plan Reviewers Name J l\� Data <br />APPLr-0±0 Uf PERF03ir A r -MgEZ CIN a �cmau �vurru ceh rum m y, t_ n*v cc ,-l.TELf1fh"S ,/U E] ABBJZ J.T3 7WS,GFSAN <br />iJD40LM C--"" E VROfAIENTAL I-ALTH O�r+AWMENr Offi SZ OR Lr -a=. AGENT'S SGMTURE CERiTF>uS TEC Fa LON19r�. -1 MUFY THAT IN <br />TI -E PEWOF� OF Ti -E WORK FOR WEIM THIS PGMT is S%j.ED, 13-fAll_ NOrEM71OY ANY PERSCAl rN aL A IrME�t32 AS TO �E Sl f 7iD <br />VYRb�2S C10MPE?CATIOti1 LAWS OF CXFCMk- CO1VrRA=1ZS HRR OR 9JB=WTRACn w, SIGNATURE CSZrGH� TEE FWDVYB� -1 OB FY <br />THAT -IN 77E-RERF�ORM r- OF THE WORK FOR WHCCH M -LS PEtMrr tS MLIED. 1 SHALL EMPLOY PERSONS SLP- TO Y ORrER S COMPEx%&TrON LAY1'S <br />OF=CALF0RfCA."k <br />I e `n� 111 l 1 i1 f P Tilk-� �5P >l)`1 -i yi) � - QI <br />BILL.1NG [MFQRMATIDN: -- <br />Indicate the responsible party to be billed for addifional B-0 staff fine expended beyond permit payment coverage per tank If <br />the party dezgnated below is d'dferent than the permit appri=ant, e.g. praperty owner the party must adrowledge this <br />responsibility for the billing by signature and date below - <br />—W <br />Ti49_: 2ai-l&1-(�3�� <br />EHM038 (revised W81067 <br />1 <br />MW <br />