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EW-VAR NMENTAL HEALTH APARTMENT <br /> SAN JOAQU N 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 /> ' <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE <br /> II BELOW <br /> UO <br /> TANK RETRFIT UFTT UPIPING REPAwRErROUDC REP ORT <br /> F EPA Site# I Project Contact&Telephone# <br /> A II•• <br /> C Facility Name 7 <br /> Address <br /> L �� <br /> I Cross Street <br /> T <br /> y Owner/Operator °r ^ ' '` Phone#_ <br /> CO Contractor Name �^ / �;" I �? Phone <br /> TContracmr dress CA Lic# In 7�� Class <br /> R <br /> Insurer work # . & �4 <br /> T ICC Technician's Certification Number Expiration Data <br /> T <br /> R <br /> !CC lnstalWs CerWication Number Expiation Data <br /> Tank!D# Tank Size Cuumntly Stored <br /> [late UST Installed <br /> T <br /> A <br /> u <br /> KPP UApproved Approved with conditions UDisapproved <br /> L (See Attachrr ent With Conditions) <br /> A �` <br /> N Plan Reviewers Name /"�\ Date '"N <br /> APPIJC/AOMUST P_ERFOf3MALLMC7RKLALA AMCF-McHSAN.IO&aMCUJUTYORDMMLICZS;.SZATELAYVS:A[1RlM A8D_R8Gb,AT]OWOFSAN <br /> "OLIN COUNTY,EW RON ENTAL HEALTH E&ARTIiE T.OWW R OR UC�AGENM SIGNATURE CE2TFFIES THE F6LLOVRJ3: -I CERTIFY THAT W <br /> THE PERFORNlA OF THE WORK FOR WHICH THIS PERMIT IS ISSLED,I SR4L NOT EMPLOY ANY PERS IN SL)CH A NAND AS TO BECOME SllB1ECT TO <br /> VYOTl 7S COMPEr�tSATIC:N LAVVS OF CALIFOFRTr1A' CONTRACTORS HIRING OR SIGMTURE CERTIFIES THE FOLLOVV94 'I CETT IFY <br /> THAT W THE PE WOR1.��1NCE OF IE WOFRK f OR VVHU-1 THIS PERMIT IS tSSkID,1 SHALL EMPLOY PERSONS SLIB.ECT TO VVCRKEFZS COMPENSATION LAWS <br /> CF CAUFOF"A." <br /> Amtssigratue C. Tdfe Mee, <br /> 411�11 <br /> BIWNG 1 MATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank tf <br /> the party designated below is ddferent than the permit applicant, e.g. property owner, the party must admowledge this <br /> responsbd' fpr <br /> ,r the billing by signature and date below_ <br /> (�fiNNAMEME PHONErne 11 I�1-t'f 71TLE C- (2zr <br /> ADDRESS l C 0 01 )'V- 2 hlr� <br /> SIGNATURE (� <br /> EH23DO38(revised&WW) <br /> 1 <br />