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- -E�IVIRQNMENTAL 1EALTH DEPARTMENT - <br /> SAN JOAQUIN COUNTY <br /> 304 East Bieber 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 /> rr ''-- THIS PERMIT EXPIRES 90 DAY'S FRO&I THE APPROVAL OATS WDICATE PERMIT TYPE BENt <br /> LO <br /> LJTANK REIROFTT L_lPIPING REPAQtrRETi c)RT Umc REPAI VFMT OFTT <br /> F I EPA Site# Pre ect CantarA&Telephone# 11m 1-c 1 <br /> CFacility Name U Phone'# <br /> � Address (� �c <br /> I Cross Stmt <br /> T <br /> Y Ownevoperator Phone# <br /> CC Contractor Nam I JC,K Phone#. <br /> N Contrardor Address CA Lic# <br /> T <br /> R insurer Work�p 9 <br /> A <br /> c ICC Tectutirsan's Certification Number Expiration Data <br /> T <br /> O ICC krstalfer's Certi6ration Number Expiration Dam <br /> R <br /> Chernlcats Stored <br /> Tank ID# Tank Sire Cnrrentty/Pneviously Dale UST Installed <br /> T <br /> A <br /> W <br /> K <br /> PLIApPmved roved With conditions U?isapproved <br /> L ii (See AttachrrentWithConddions) <br /> NFPlan'Re�Wewefs,Name N Date <br /> APPLICAts[fMUST F_ERFCgU.A4k.SN[7RlC_ •��JWL)OtlallY!�"_id��STAIEl�AV1GSi:AtIZR1A�S.A6B :OF SAN <br /> JOAC LAN COUNTY,E WRONME TEAL FEAL :-EPARTNENT.GNRJER OR LMSED AGENM S13MTURE CERTIFIES THE Fl7LLOlf -1 CE TI Y THAT IN <br /> THE FBWCRN{ANCE OF THE WORK FOR WHIR TM PERMIT IS ISSUED,I SHALL NOT E NUN ANY PERSON W SUCH A MANCE ASM BECOME S MIECTTO <br /> MIK]03rS C0&fE34SATICN LAWS OF CALIFORNIA.' CONTRACTOR'S HfRWGOR SUBCONTRACTM SKMTURE CERTIFIES THE FOLLOMMIS' 9 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHK}i THIS PERMIT Is MUD,I SHALL EMPLOY PERSONS S JE. TO NIORICFR'S C OIN ENSATION LAWS <br /> OF GAUFOF*W <br /> pppycartsSlgrm4re To. Deme <br /> BIWNG t RMATION: <br /> indicate the responsible party to be baled for additional END stalf fine expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the .party must admowledge !tris <br /> responsibirdy forthe billing by signature and dale below. <br /> NAME ��1 0 ! U����C � 7TTl E N�I Q��Y11�1��PHONE �vC� 4I-h -� <br /> SIGNATURE <br /> EH23D=(revised 8l8IOt's) <br /> 1 <br />