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ENVIRONMENTALEALTH DEPARTMENT <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 /> THIS PERMIT DKPIRFS 90 DAYS FROM THE APPROVAL UTE INDICATE PERMIT TYPE BELOW <br /> UTANK RETROFIT UPIPLNG REPAWRETROFTT L-6x REPAIR/RETROF 1T <br /> F EPA Sim# Prejed Contact 1�Telepthone: <br /> A <br /> C Faciiiiy Name �' Phone# <br /> LAddress ]JILL — c-1 c — — �. C c <br /> I Cross Street <br /> T - <br /> Y Owner/Operator �� Phone# <br /> Co <br /> Contractor Name - L Phone# <br /> TContractor Address s CA Li.# Class , <br /> R Insurer Work Comp# <br /> A <br /> cICC <br /> T Technician's Certification Number Expiration Data <br /> ICC <br /> R lnsfatlees Certification Number Expiration Datta <br /> Chemicals Stored <br /> Tank 1D# Tank Size Dale UST InstalledCurrently/PreViD-ly <br /> T <br /> A <br /> K <br /> P UApproved '-�pproved with conditions UDisapproved <br /> L Attachu nt With Conditions) <br /> N Plan Reviewers Name Date <br /> APRJCAW MUST PERFORM ALL S6C]R C MA03OMDANCEWULSAU0aWTY CIRU wpIqF-S,-IZATEI_ANts AMUM AES neo-RPGULADONS,CF SIN <br /> - <br /> jaAGLRN COUNTY,E3WROt MENTAL HEALTH CPARTMENT.cwER OR LICBzs D AGETIT'S SIGmTURE CERTIFIES THE FOLLOYIB43� n CEtTiFY THAT IN <br /> THE PSU:U ANCE OF THE W RK FCR VNiIOH THIS PERW IS LS3 IED I SHALL NOT EIQ-'i OY ANY PERSCN IN SUC}R A t IAt,C AS TO BECCI►tE&A� TO <br /> VVORKE Z'S CO&PENSAMN LMS OF CALIFCRNUI' CONTRACTORS HIRING OR S*G JATLJRE CSZITFIES THE FOLLOWTOa. 'I CERTIFY <br /> THAT N THE P62FORMANCE CF THE WOW FOR WiICH THIS PERMIT IS ISSIID,I SHALL EMPL OrY PERSCM SLELECT TO V4CR0(EtS COWEWATKDN LAWS <br /> CF CALFUMA-' <br /> Tfi- ' Oatr I <br /> f BIWNG f RMATION.- <br /> indicate the responsible party to be billed for additional EHD staff&)e expended beyond permit payment coverage per tank If <br /> the party designated below is different than the permit applicant, e.9- property owner, the party must aclamwiedge this <br /> responsibility for the Ming by signature and date below. <br /> NACRE C ; l j m L l t ic. a Cd'f i rLE <br /> ADDRESS—z., I� 1���tls�iti ��f T �k�7cyf1; ��7C)S <br /> SIGNATURE - i l� i <br /> EH23DO38(revised WW) <br /> 1 <br />