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I F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />T <br />A <br />R <br />K <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East WeberAvenne, 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 PSWIT EXPIRES 90 DAYS FROM T}1'_ A.L DATE pjrgr4TE paa'Mrr TYPE wo ^W <br />UTAH: R-E-MORT UPIPING REPAWRURDFIT <br />UuDc REPAIRlR_G}'ROPT <br />>✓r A Sib # Project Canh� & 7elephorw_ # , 2 � <br />Yui(._ l; <br />Facrlity Name G <br />Phone # <br />Address lc __ <br />li�c1. C' <br />Cross Street <br />0—JoPerator Phone # <br />G 1 c <br />Contractor Name I <br />Pune # <br />Contractor Address r <br />2,155 -CA # Clams 1 <br />Insurer <br />ci P W, , ' _f 4Cl 1 11LU U O <br />ICC Tedriicen's work Comp # <br />Certification Number <br />Expiration Bah, <br />ICC kzstalkWs Cerfific-anon Number �ation Date <br />Tank ID # Tank e Chemicals Stored <br />ScCIla [IST Installed <br />urrently PreviDushf <br />ID UApproved <br />L <br />A <br />N <br />Plan Reviewrers Na <br />with c=cktions UL)sappmved <br />With Conditions) <br />W <br />APr3XJ�tCI1dLL4PSW RMAI r-MORKKA.rrrxmanrrWRiSAN XMIaMmCOiTY.Cs�6lAGICF�..gATE. <br />I�iNtS ,As@ A8B_R�=Gik�lT3�LS.QF SAfd <br />JOAC7�N CXXJNTY, �/CRON3ABJTAL rEALTH O<A4R77Je3n. CA1tEiZ OR LUMSED AGBgM S5.TU E TI -E Ft' l-OV4@ja- 'I CITIFY THAT IN <br />TFE PUYUR ANCE OF Ti -E WORK FOR AAM TEES P=RWT tS tSSLED I SHALL NOTEMPLOY ANY PERSC N W SLUR A MANNER AS TO BECOME SLS= _-TTO <br />�►' ATKNANC LIF=T OF CALOW, P p CONTRACTOR'S H RW OR ITRACTM SK3t ATURE CSZMES TFE Fal M43- 'I CR?TFY <br />T�-IAT.IN 7}E MAM � OF THE WO2K F2? H �;:� ?T'. 5 T -^,'+i,, r3 ISS E). I SHALL EMPLOY F�oh6 sLe EGTTO <br />a= C'WrOF2MA' tNDr'ilCStS CX71L°G_l.5ATpN tJiKS <br />I +e 1�I11� l�'�`•S� TdEWC')FlllC`�i�,V�.1 �e 1'�- 11 <br />BIWNG tN RMATION: <br />Indicate the resPonsi5le Party to be bitted for additional END staff fine ended beyond pe. -nit Payment coverage per iankc If <br />the Party designated below is Merent than the permit applicant, e.g. Property owner, the party must acfaoowledge this <br />responsibility far the bang by signature and date below_ <br />NAME <br />ADDRESS�P 959-617) <br />SIGNATURE <br />B-123DO38 (revised Waw) <br />