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...'21120C9 1hBD 16:42 FAX 20�i4683433 3JC zac <br />n <br />DEPARTMENT111 11 <br />ENVIRONMENTAL 11EALTH <br />SAN JOAQUIN COUNTY <br />600 Fast Nfain Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />poos!00T <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />Ih4S PERMIT EArHRES IBD DAYS FROM THE APPROVAL DA'E. NDiCATEPERM:T TYPE S EUDIA <br />! iTANK RETRGFiTPIPING REFAIR,RF..IFUFIT (�LUC 2E�a;P1�ET«I=;T CJL ST;,RTIedR UPGRADE <br />AI EPA Sae .# Project Contact & Telephone # <br />C Facility Name A Phone # <br />L Address ' l..j r i_. ---- <br />cross straet ° <br />Ownerl0p- <br />eratar <br />CDntractcr Name <br />1-2) <br />ContraclorAddress f• <br />, <br />r. .. <br />Insurer <br />ICC Technician's Certification murlb- - <br />R CC Installer's Certification Number <br />Tank ID <br />Phenet <br />CAglass <br />Work Comp # <br />Expiration Date:� -- <( 1�n <br />� f <br />Expiration Date <br />Cnernlcais Stored i <br />CUrrentiylPlevi:xasiy Date UST Insta;led <br />P {Approved -r — — •— <br />L Approved with conoitlons Disapprowera <br />A (See A chmentMhth Conc:lionsi <br />i N .w ,� <br />Plan Reviewers Name l a -- Dae � � vi �' y <br />/— — <br />PFPU1,,NN7 MUST P;RFORM ALL WORK IN ACCORDANCE WITH SAN jOAOUIN COUNrf Gfit'I'dAN(: £, s.rH.F iA S, AND RULES ANC RF-GuLak ONS CF SAN <br />'UPOUlm COUNTY €NVIRONMENTAL HEALTH DEPARTMENT. OWNER JR LICENSED AWNT'S 3VAI'L'RE CLRTt" I[5 TH_ FOLLOWING: .7 CE r,ON THAT IN <br />T!;E PERFORMAtvCE OF THE WORK W3R MACH TMS PERMIT IS ISSUED, 1 St4ALL NOT EMPLOY ANY PERSON 1N SUCn A MANNER AS TO 6EI CER .r Y T CT TO <br />CMFEUSAT.ION ✓1VS$ OF Cr1L1=0RNIA." C v^NTFACTOR'o ! IRING OR SUBCCNT- 64.,7N: SlG�1ATJRE i, -R7' =!cS THE F^LL l�^I :JI ; '! CER -Irl' <br />ra ('N -HE PERFORMANCE OF TAE WORK FOR W-i.CI T' IS "ERVIT IS ISSUED, 1 $HALL EL4PLO, PFRSCNS S�'9JFC i rC7 W S 1 ER'$ C.:W;IE Q; ' It rJ RIMS <br />OF CA-IFORN:A: - Xf <br />APoi:;aMsSigriatwra, `^ <br />r Cate J <br />till.-ING INFORMATION' " <br />1-0cats the responsible party to be billed For ackifional EHD staff time expended bey'a-rd perrlot PLyment -:overage pe� talIK f <br />tea party designated below is d fferant than the pe -n -It applicant, e g property auier, the party , rLSt ackrowleege this <br />-as pon b;Jit orthe ni#�ling by signature and ease below. <br />Nhth= 1��' ►h i` S� TITLE_ <br />t w - <br />ADCRESS ��. r {�.... Lr. s(,4 C <br />b'I(�tVA <br />GF12300?8 <br />1 <br />Z•d 6COZ-L88-60Z uiaeQ d99:90 60 ZO 9a_j <br />