Laserfiche WebLink
i <br />-EMVIRQNMENTAL 14EALTH DEPARTMENT -- <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 PEIMU EXPIRES 90 DAYS FROM THE APPROVAL DATE WWCATE/MWfr TYPE BU0W <br />I TANKRF'rRAFfT l_IMW.REPMMEIROFff I Lk=REPAIIWMM0RT <br />F <br />I EPA Site # <br />Project Cardact & Telephone I U/ <br />C <br />Facility Name <br />( hone # 33 f - <br />I <br />L <br />Address 1/ <br />%nC( i/f <br />Cross Street <br />Y <br />OwnerA)perator <br />Phone # <br />C <br />O <br />Contractor NamePhone <br /># <br />Contractor A41ress <br />CA Lic # Class L4-,106 <br />A <br />Insurer <br />VYork Comp # ` <br />T <br />ICC Tedmician'sCertification Number <br />' p� 'u t Expiration Data,_ wie o'Z.3 f D <br />O <br />R <br />ICC InstaWs Certification Number <br />Elation Data <br />Tank ID # <br />Tank Size <br />ls Stored <br />� � <br />Dale UST Installed <br />T <br />A <br />M <br />K <br />P <br />UApproved <br />OWroaed With can&tions UD'sapproved <br />L <br />(SeeAttachmentt M Conditions) <br />A <br />N <br />/�,(j� <br />'' <br />C <br />Plan <br />Reviewers Name r 1 <br />Data <br />APPI.ICA6QMUSrPERFCPLX1..14PE4K-L<+CArrnanan►xyy4Tl3SMI..106WINDOLmrIY <br />-*-M- S,.!9WW2-1AV1t�S-:Ap[x�1L�S.AisBRE OF SM <br />JOAC7 M <br />COUNTY, ENVIRONMENTAL HEALTH hPAR771i3dL <br />OM OR LK24SM AGENTS SIGNATURE CERTFIES THE FCLLOYA 43- -1 CERTIFY THAT IN <br />THE PERFORt <br />AW;E OF THE WORK FOR WtileH TFIIS PERNT tS ISSIA, I SK L N0T EYP1:DY ANY PERSON W aXI•I A t tAtJN ASTO BECOME SUBJECTTO <br />WC7RKEIrS <br />WS OF CAUFORM <br />ChrrRACTU S HPJNG O R RMOONTRAC M SM47URE CBMFIES THE FOLL MMIIG'1 COY <br />THAT IN TFE OF TIE WORK FOR <br />PBwff is {SSU®, t SHALL EYP!!JY anECr TO CoYPETISATIDN LAWS <br />CA[�FORNIJI' <br />7/1 <br />IJILUNL-i INt•U10AM IUN: <br />indicate the responsible party to be billed for additional EHD staff terse expended beyond permit payment coverage per tank. If <br />=Pthe party noted be{ow is different than the permit appfirant, e.g. property owner, the .party mast adorowiedge this <br />1 forthe hdfmg by sig re an �Jda�te�below. f�% /J / /�- <br />NAM I V 77TLE E # 'LC_1G [ � 5,3 " <br />4DDRI SS <br />Zir-MATI 11 bY)l <br />EH23D= (revised 818!!16) <br />1 <br />in <br />