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VIRONMENTAL H-EALTH DEPARTMENT ---- -- - - - <br />SAN JOA(QUIN 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 />t ' THIS Pa MIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOWBELO <br />UTANK RETROFIT UPIPING REPMMETRORT i__6)c REPAIR/RETRORT <br />P <br />EPA Sim # <br />Prejed Cardact & Teler>ttaneAM-u--41PI-183'11, <br />CFactTity <br />Name <br />Lit, <br />�'� hone <br />r <br />L <br />��A160 <br />Address /LW/ <br />Cross Street <br />YOMrt�erlUperat-r <br />Phone # <br />C <br />0 <br />Contractor Name <br />Phone # <br />T <br />Contactor ss <br />G(1��,1 - CA U. # .. ,000Class d-- o <br />AInst <br />ner <br />Work Comp # <br />7 <br />!cc TecFutician's Certification Number <br />, ' ' t ExprraUon Daba�u��� 3r b <br />44 <br />o <br />R <br />ICC lnst~s Certification Number <br />Expiration Date <br />Tank fD # <br />Tank Size Cur��ntlY/P a a�91slY <br />Dille UST Installed <br />T <br />A <br />w <br />K <br />p <br />LI4ppra red <br />OAppmwd with c mu"E5ons UGisapproved <br />L <br />(SeeAtlacttment With Conditions) <br />A <br />N <br />hS6` <br />` <br />3' <br />Pla�Reviewers.Naffle <br />DateAPPiCANTP_ERFML4LL. <br />CIN- <br />l0*qtor49purY.nwrrc SidIELlIYItS-:ANQ SA6B :GF SAN <br />J ACUJIN COUNTY, ENV5bh MTENTAL HEALTH UEPARTMENI: <br />aMN M OR LICSISE) AGENT'S SIGNATLIRE CBUFFS THE Fi7LLOM*G: 'I CEM1FY THAT IN <br />THE PERFIORLMIC.E <br />OF THE WORK FOR VMM THIS PERYCT IS ISSN I SHALL. NOTEMPLOY ANY PERSON W S ICH A UANER ASTO BERME SL[d3-,TT0 <br />WOi2K3rS <br />C0MPENSVftWUVVS OF CALwavw <br />OONTRAcraRs H zmcR SICK auRE csmFiEs THE PCA omm 9 C871IFY <br />THAT IN TFE OF THE WC W FOR <br />Pawff Is issm. t SHALL EMLPLgY S UB.ECT TO COMPENSATION LAWS <br />OF cALI Sig'A - <br />7/1K.. /��IfF � Jl% 0A DA <br />lJIU.INU INt-UKMATION: <br />Indicate the responsEle party to be billed for additional EHD staff fine expended beyond permit payment coverage per tank. If <br />the party rated below is different than the permit applicant, e.g. property owner, the .party mast admowledge this <br />respo for the bitfmg by sig re�d�ate)below. <br />NALIE a� c/ u' TTTI E lfl E 9 'LCJG L � �✓"7- <br />ER23D= (revised &18W) <br />Z <br />`2- <br />