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ENVIRONMENTAL E�iLTH DEPARTMENT <br /> ...SAN-JOAQUIN.COUNT'S .: <br /> 304.East Weber Avenue,Third Floor,Stockton,California 95202 <br /> :Ti!ePhone: (209).4. 3420 :Fay: (209),468-3433 . <br /> APPLICATION.FOR UNDE�tCROUND.STORAGE TAN ..RE IT OR:PIPING REPAIR-PERMIT <br /> �77 THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMn TYPE BELOW: <br /> IJTANK RETROFIT, OPIPING REPAWWTROFIT ©UDC REPAUi/REn20FIT <br /> F.: FPA Site# : Project Contact&�'elephoho# <br /> A .. <br /> C Fac7ity Name . :. U Phone# �. . — <br /> I Address <br /> L � c <br /> Cross Street : ` - <br /> Owner/Operator — <br /> Phone# <br /> o: intrador Name L _ <br /> tj <br /> T <br /> Coptcactor Address' CA Lac#•� <br /> �Q (� pass . _ t <br /> •A Insurt;r Wofk Comp# <br /> C. <br /> T ICC Technicians Ceififica&q Number �ira#oq Date <br /> •o <br /> Ft IGC Installers Certifigtton iJumt�er Expiration Date . <br /> Tank ID# Tank S¢e. Ctiemt*a Sfoced :: : <br /> Cilrrentl%Previous D �Sl tnstafed . <br /> Y ly <br /> A. ; <br /> P Approved MApproved.with oondifions' Disapproved <br /> _ ._: <br /> (See Attic hnwt*dh Condifioas) <br /> Plan'Reviewers Name Datef <br /> iIIlWS1 P QRM ALL YYt iFC tN ACCORDANCE WITH-SAN JO AQUIN COUNTY ORD94ANCES STATE LAWS AND RULES AND REGtNATIDNS:OF SAN <br /> JOAQUW COUNTY,=MENT•AL H AI.Tkt DEPARTIIMT OMER'OR L AGENTS.SIGNATURE•GERTR IES.4w FQLLOW9rG;.M CERTIFY THAT IN <br /> -OF41�WORK-FOR WH(q•I THS PERMIT IS ISSUED:I SHALL NOT OMNI.-0Y i W PERSON--SUCH A MANNERAS.TO BECOMESI CT To <br /> Wa15 CDUB?9+ISAT70N.LAWS OF:C/WFfNtNW* CMRRACTORS:HIRWG OR.SUBCDNFFiACTINGSKb4TURECERTIF9:S THE. (x1U1N9IG:.9•ttTIFY .: <br /> 7YJA��I.T�IE♦ QRR>IF CE.DF.THE iN K FOR WHK�i•THIS PERMIT IS SD,'l S4iAl1 EMPIOY FERSDPRS SUBdC-GT TO WAR'S ONLAWS <br /> CALoRN1A 1 , <br /> ;.APPS S 4 <br /> BfL G I. 'A <br /> FOR. : Date <br /> t : ndl atB:the: pi�O$]L�le rty fe-be:fdlllf,'d.�Ql addl�f06 staf��fi e11(6 <br /> 0( CiTNt= d�Y{1tEnt GDVBrd_t f& =tC. tf' <br /> - <br /> _ P"�Y owner, mus .a ihls___ - <br /> -tkt)Ttflefi�h` sl _ <br /> Mr Y l*Wtute am nate�eiow <br /> .- 1 �_ ..�� ctlkt}t I P <br /> k _ y <br /> 3 <br /> { I �11tvi ,5 ('xrrt � 7 <br /> SIGNATUREll'1�1 <br /> E.t•12$t)Q3s cruet W06):. <br />