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82/05/2009 08:11 <br />9163712450 <br />0 <br />BZ MANITANEM0E <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (2,09) 468-3420 Fax: (209) 468-3433 <br />PAGE M3/13 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 100 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW: <br />Indicate the responsible party to be billed for additlonal EHQ st2ff time expanded beyond permit p2ymartt coverage per tank. IF <br />the party designated below is different than the permit applicant, e.g. prqper�y owner, the party must. acknowledge this <br />responsibility for the blIfing by signature and date below. <br />NAME PHONE <br />rrLE <br />SIGNATURE <br />F.mnuooae«avmem12m1mr <br />I <br />y <br />PUT <br />j <br />Expiration Date <br />d7ri'llk <br />Chemicals Stored <br />Indicate the responsible party to be billed for additlonal EHQ st2ff time expanded beyond permit p2ymartt coverage per tank. IF <br />the party designated below is different than the permit applicant, e.g. prqper�y owner, the party must. acknowledge this <br />responsibility for the blIfing by signature and date below. <br />NAME PHONE <br />rrLE <br />SIGNATURE <br />F.mnuooae«avmem12m1mr <br />I <br />