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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN 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 PERYfT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMrT TYPE BEL06V <br /> UTANK RETROFIT UPIPING REPAPIREIROFIT I_k=REPAWRUT T <br /> F EPA Site# n Prejed Cantacl&Telephone# <br /> A Phone#, L%�j <br /> c Facility Name � � ti <br /> I Address \ <br /> L 42 <br /> I Cross Street <br /> T <br /> YOwner/OPeratar jPhoneo ContraclnJN ne# jC / /�7��3 <br /> N Contra r ss i— CA lic <br /> AInsurer ✓ Cc 7 / Work Carp <br /> TICC T 's Certifa�lion Number Expitalion Date <br /> R Number klstalkWs Certification Niber Expiration Date <br /> Tank 1D# Tank Size Chemicals Stored [lateUST Instaf}ed <br /> Currently/PreviOUS* <br /> T <br /> A <br /> u <br /> K <br /> P UFlppr ved YfAwroved with conditions UDisapproved <br /> L (See Adachmnt With Conditions) <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PIER FUM ALL 1NCRK M ACCORDANCE 1MTH SAN jaka x c"I7Y ORDINANCES,STATE LAWS_AN RLtES AAD.REC,[A_ATIONS,OF SAN <br /> JOACXAN COUNTY,ET IRCINWNTAL HEALTH LEPARTMENT"OWNER OR LlC&:SD AGENT'S SGf-ATURE CERTIFIES THE FCLCFAW8 '!CERTIFY THAT IN <br /> THE PEI:d ANC OF THE WORK FOR V4F[ICN THIS PERMIT IS ISSLIED,I SHALL NOT EHPLM ANY PERSON W a"A I A NER AS TO BECOME SL ULECT TO <br /> aF-7=az�� <br /> VYS OF CALIFCRTIIA' CONTRACTOR'S HIR-WOR SrNATURE CETRTWIES THE RJLLOWNG 'I CERTIFY <br /> F THE WORX FOR WHICH THUS PERMIT IS SHALL EMPLOY PERSONS S<1SECT TO VV ORKE7s COMPENSATION LAVYS <br /> CALFORMA,' <br /> BILLING ATION: <br /> indicatethe responsible party to be billed for additional EHD staff tine expended beyond permit payment coverage per tank If <br /> the patty " mated below is different than the permit appficani, e.g. property owner, the party mast acbwwle�e this <br /> responsb rtyr for the biifing by sig re and date below_ <br /> NAME <br /> I I� T1TLE PHONE# <br /> ADDRESS / <br /> SIGNATURE ' <br /> EHt23DO38(revised 8/8106) <br /> 1 <br />