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u�i-'u/-luub WISD .tb! 1a VAX Stockton 5ery sta E¢ Ca Ian ;;cn <br /> Iq S <br /> 5� <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 Ci a$t Main Street,Stockton,California 95202 <br /> T-01epholle; (209)468-3420 Fax; (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXr�P��IRR12S 160 DAYS OM THE APPROVAL DATE. INDICATE PERMIT TYPE-OR40W; <br /> i <br /> jr"ANK rlrTROFI'r �VIPININ0 KEPA`IP/Re7it0f�l ,�7UOC REPAIRIRErRCFI- ICOLD START/EVE UPGRADE <br /> _ ...�. <br /> --l- <br /> FPA Slia kProject Contact&Telephone <br /> ,; Facility Name ---�—�, <br /> 00 <br /> t. Adclroas� IL <br /> 1�1 <br /> Phone#ZO <br /> (' Contractor Name c� <br /> o — Phone i'x .... <br /> N .^.ORIr7ClOr Addre55 / I <br /> T o. # N/.Q ,• CA t,i0 tE �p _ cies <br /> R .....-actor <br /> C -- - Tom' +p, —_ Work Comp <br /> T ICC•I'r_chnicialt;Cerliilcation Number Expiration Date <br /> 0 ----- ...,..» <br /> R U1 In^lHlle_rs Cert1111atlon Number Expiration Date <br /> - Tank ID# Tank Size Chemicals Stored Waite UST Installed <br /> Currently/Prevlously <br /> A <br /> K �— <br /> F �lAppmved Approved with conditions ��Dlsa�arove <br /> L <br /> A (9139 Attachment With Conditions) <br /> N I Ilan reviewers Name_ - __.. <br /> _��� l!`�------ Date. <br /> APPLICANT MUS"1'PERFORM ALL TRK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF SAN <br /> JOAOIJIN COUNtt " <br /> ONMF_'h I' L HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THS PERFORMAHE WOI t FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO F.GCOME SUBJECT TO <br /> WORKER'S CUM HIRING OR SUBCONTRACTING EIGNATUR CERTIFI THF FOLLOWING' "I CERTIFY <br /> THAT IN TH OF iE WORK FOR WHICH THIS PERMIT ISSUED.I SHALL EMPLOY PERSONS SUBJECTTORKOR'S COMPENSATION LAWS <br /> OFCALIFORN e.A �— - <br /> BILUNG INFORMATION, <br /> Indlrete the responslbla'party to he billed for addili4ngl Eyb Staff itme expended beyond permit P yment coverage per tank, If <br /> the pally designated helow IS different than the permit appllcmnl, 9.9. property owner, tale party must acknowledge this <br /> respunglhillly for the billing by signature and date below. <br /> 7i7tE �—y�<?53'Z_.._- --rlanvr-.rt�� , � � -- <br /> ADDRESS <br /> SIGNATUR <br /> EH230038(revised 12.!91/07) <br /> :I. <br />