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I--- ,.., ,. <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN 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 />Tank -W-# _ _ _._ �. Tank Size.. �_- .__CliernicalsSlared. <br />T <br />A <br />M' <br />K <br />-- We UST Installed ._ <br />IP Lkpproved *pproved W-0 Ctrs UDmVpmved <br />L (See Attachment With Conditions) <br />A <br />N Plan Reviewers. Name! <br />APaJCAt+tT llL1ST r FPn A r . 1d9C1lmtD0i IIITY d ..Sr_AiE AM►l.S�,AeICs FS. AeQ <br />-IOAom coumly, 9JVRONMB�lri1L FF.ALTH �iARiMB�[T Uw4m Oi7llC sED AGmm sGmniRE cew FTEs -n E FOLLmAck 'I csMN THAT fM <br />THEPSWRMANCECFTHEW0WFCRVI4MTHS R3WrSISS[IED.tS?ikLNdrBffUWANY POaMWSL04AM/ &t AS70MOMESBJSCT70 <br />VYCR MM COMPS"TEN'LAWS OF CkA:X VW CMPJZMS HRMOR S SOMRACM-S SM47LIRE CBMIM THE FAUN A M 'I CBMFY <br />THATAIEPERFORMANCELFTHE VV,'MFOR V*UCH7MPauffrSssmpLStvmBmOYF'i mus 9uaEGTTQYYORKHtsCoupEwATIONLAWS <br />CF CACPQA' <br />je4-,%M I 1 \1A, <br />Indicate the responsible party to be billed for additional EHD staff fine expended beyond permit payment coverage per tank If <br />the party designated below is different than the pennit apprmrtt, e.g. property owner, the .party must acbmwledje this <br />responsibEty for the billing by signature and date below- <br />NAMs_ _ Ihtm i nt Tint PHONE* <br />SIGNATURE <br />EH23D= (revised 13/8!06) <br />Z <br />7m PERMIT EMRES 90 DAYS FROM THE APRLOVAL DATE #4WATE PE—RW TYM BaOIk <br />UTANK RETROFIT <br />L-6vnNG REPArt/R mcnT <br />Lk= REPAtRmuROFIT <br />F <br />EPA Sb # <br />ProjectCw art & Telephone # <br />A <br />C <br />Facility Name <br />Phone # - <br />LAddress <br />A <br />TCross <br />Street <br />1' <br />OwnerlOperahu <br />Q <br />Phone # <br />C <br />Contractor Name <br />U <br />Phone # _� <br />N <br />T <br />Contractor Address <br />CA tic # <br />1 Class <br />A <br />InSUrel t 1 <br />Work Comp # paxlf)l <br />TICCTechnician's <br />Cerbfta an Number <br />Expiration Dai <br />RIcc <br />krs$alfer's CelliSC2110n Number <br />Eap ration Dale <br />Tank -W-# _ _ _._ �. Tank Size.. �_- .__CliernicalsSlared. <br />T <br />A <br />M' <br />K <br />-- We UST Installed ._ <br />IP Lkpproved *pproved W-0 Ctrs UDmVpmved <br />L (See Attachment With Conditions) <br />A <br />N Plan Reviewers. Name! <br />APaJCAt+tT llL1ST r FPn A r . 1d9C1lmtD0i IIITY d ..Sr_AiE AM►l.S�,AeICs FS. AeQ <br />-IOAom coumly, 9JVRONMB�lri1L FF.ALTH �iARiMB�[T Uw4m Oi7llC sED AGmm sGmniRE cew FTEs -n E FOLLmAck 'I csMN THAT fM <br />THEPSWRMANCECFTHEW0WFCRVI4MTHS R3WrSISS[IED.tS?ikLNdrBffUWANY POaMWSL04AM/ &t AS70MOMESBJSCT70 <br />VYCR MM COMPS"TEN'LAWS OF CkA:X VW CMPJZMS HRMOR S SOMRACM-S SM47LIRE CBMIM THE FAUN A M 'I CBMFY <br />THATAIEPERFORMANCELFTHE VV,'MFOR V*UCH7MPauffrSssmpLStvmBmOYF'i mus 9uaEGTTQYYORKHtsCoupEwATIONLAWS <br />CF CACPQA' <br />je4-,%M I 1 \1A, <br />Indicate the responsible party to be billed for additional EHD staff fine expended beyond permit payment coverage per tank If <br />the party designated below is different than the pennit apprmrtt, e.g. property owner, the .party must acbmwledje this <br />responsibEty for the billing by signature and date below- <br />NAMs_ _ Ihtm i nt Tint PHONE* <br />SIGNATURE <br />EH23D= (revised 13/8!06) <br />Z <br />