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- ElltVtR-—ORlofETIjTAC-H- F�ILTH DEPat�T117�ENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone:(209)468-3410 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 BELOW <br /> UTANK RETROFIT UPIPING RFPARmETRoFiT UUDC REPAIR/REIRORT <br /> F EPA Site IF Project Carhtart&Telephone CL K 6L rfi I 33 7 <br /> A <br /> C Facility Name I Phone# �s _ <br /> L Address ?j' �� < C <br /> I Cross Street <br /> T _ <br /> y Owner/Operator ra 0 Phone# P- <br /> CO Cantrador Name Phone# <br /> TContra c"dress ` ' ��yIfA��' CA tic# Class <br /> R <br /> A Insurer Kr( a4A Work Comp#. <br /> TICC Tedmicsan's Certification Number Expiration Data <br /> RICC lristaWs Certification Number B#ation Date <br /> Chemicals Stored <br /> Tank ID# Tank Size Currently/Previously Dale UST Installed <br /> T <br /> A <br /> w <br /> K <br /> P UApproved UApproved with conditions UDisapproved <br /> L Attachment With Conditions) <br /> H Plan Reviewers Name <br /> APPtKAMT My PERFLIRM.ALL WOM.& ..._.... sAN JoAa McoubrTY OI�DIANC�,S,.STnIE CANIS;At[T 86 f AM-RECUATKN,s:of /W <br /> S <br /> "OLM COUNTY,EWIRONMENTAL WEALTH DEPARTMENT-OWNER OR LICB:SED AGENT'S SIGNATURE cezrFIES THE FOLL0IvRs3- -I CERTIFY THAT IN <br /> 7HE PER�PERFCP*APOCE <br /> W ICE OF Y10RKFCRWHCH THIS PERMIT IS ISSLII SFNIL NOT EMPLOY MIY PE FZ O W SUCH A LAA R ASTO BECOME�7 TO <br /> YwORiCSLAWS OF CALIFO IAL' CONTRACTORS WRING OR SC44ATURE CERTIFIES THE FOLLOVVIX '1 CERTIFY <br /> THAT W OF THE WOW FOR / ►IIT S ALL 7c , <br /> 7( w <br /> SUB.ECC TO NORKERS COMPENSATION LANES <br /> OFI/L- �l�� q Ll d <br /> BIWNG( RMATION- <br /> indicate the responsible party to be billed for additional END staff fine expended beyond permit payment coverage per tank tf <br /> the party designated below is liferent than the permit appr-icant, a-g. property owner, the party must acknow6dge this <br /> respon itftyy for the bdfing by signature and date below- <br /> All <br /> NAME � TITLE PHONE f V / / <br /> ( G <br /> ADDRESS <br /> SIGNATURE <br /> EH23DO38(revised 8MM) <br /> 1 <br />