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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUN COUNTY <br /> 304 Fast 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 EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMrr TYPE BELOW <br /> UTANK RETROFIT UP2F7N G ' <br /> REPAPIRE2i r ORT UUDC REPAIR/REMORT <br /> F EPA Site# Project Cantact g Telephone# <br /> C Facility Name Phone# <br /> L Address <br /> t <br /> r Cross Street <br /> Y Owner/Operator <br /> Phone# <br /> C: Contrar-br Name ` PP <br /> N Phone# . `� l <br /> T Contractor Address L <br /> R +�> �,_)( � CA f_ic# Class <br /> CInsurer Work Comp# <br /> T ICC Technician's Certification Number <br /> O E)irabw Data <br /> R ICC Installer's Certification Number Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currenffy/Previously <br /> T <br /> A <br /> u <br /> K <br /> P UApproved <br /> L NApproved with conditions UDisapproved <br /> A (See Attachment With Condifions) <br /> H Plan Reviewers Name /)I j�'���1r <br /> Date <br /> APP1lCAM MUST PERFC1RM ALL"KXZI(L^L Y4rM,-'AN JOACY.fA1COUNTY OE DMNg;S,.STATE tAWS-:AND- A6D_REGU ATIONS O SAN <br /> JOAOUAN COLROY,ENVIRONIMENTAL HEALTH-DEPARTMENT.OV41 R OR UC&ISED AGENT'S SIGNATURE CERTIFIES THE FOLLCYJrRIG: '!C82IifY THAT M! <br /> THE KEI?S COMPENSATION <br /> F THEA ION WORK FOR WHIALIF FI THUS PERMIT 1S ,1 SI-ML NOT EMPLOY ANY PERS IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> VVIJ�'f(ERS COAPIatSAT10N LAWS OF CJIUIFOFRNIA' OONTRACTCR�S HIRWOR SIGNATURE CERTIFIES THE FOLLOWING 'I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE VVCIRK W+C H THIS PERMIT 1S ISSIM.1 SHALL EMPLOY PStSONg SJB.,ECr TO VVORKERS <br /> OF CALIFORNIA�_ C�d[PET�ATIDN LAWS <br /> T&- SC n <br /> I <br /> BIWNG INFORMATION: J <br /> Indicate the responsible party to be billed for additional EHD staff tine expended beyond permit payment coverage per tank If <br /> e party designated below is different than the permit appficant e.g. property owner, the party must acknowledge this <br /> responsi ility for the billing by si `ture and date below_ <br /> f"E \ mCC 1� TITLE I" PHONE# <br /> ADDRESS � C �� C, <br /> SIGNATURE <br /> EH230038(revised aW%) <br /> 1 <br />