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d11 d'lf Zf116 15:45 5596E�7 <br />FRANZEN HILL • <br />PAGE 01 <br />EHEALTH EALTH DEP RTMENT <br />SAN JOAQUIN cOUNTY <br />186$ E. Hazelton jAvO,, Stockton, Callforrlle 96205 <br />Telephone: (los) 468-3420 Fax: (209) 463-3433 <br />APPLICATION FOR uN PINS REPAIR PERMIT <br />�� <br />RETROFIT OR PI. <br />THIS PERMIT EXpiRES 180 DAY$ FROM THE APPROVAL DA71n. INDICATE PERMfT TYPB BELOW: <br />TANK RETROFIT 0 PIPING REPAIRIRETROAtT 0 t3CJC R pA1RJ <br />ClRETROrIT 0 C()Lla STAR t7EVR UPGRA012 <br />7 <br />A <br />N <br />K <br />QApprovedApproved with conditions <br />Disapproved <br />P hment With Conditions) <br />A pate <br />M Plan Revlewers N$ <br />�PPLIGiINT NNST PERPeRM oRlc IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />aYAi>; tJ4YY5, AND RU4.)=3 ANt] RFAULATICNg t>g eAAi <br />NG $1GPIATURE CERTIFIES THE FOLLOW1Ntk I CBRTtFY <br />FOL <br />7HRr 1NGRK FdR WHICH TliFS PERAAn 188iJErti, I S11P•LL NOT E MPLQY ANY PERSON IN SUCH R NIi1NN@R AS T4 BGCOME gU8JE0 r TO <br />oA4UlN CdUNTY, ERF RONME Rt M9EtsLTN p>rpAFt7MAENT. OWNER OR LICENSED ADiNTB SI(ANATURE ceRTISES THE VI! eS TO 9 OGf2Tl <br />pERF4RMAMICE 0 <br />�p}q(�'B GgMP6N6AT1Oiti1 rAWS OF CALIFORNIA.' OO�pTORS HlR1NG QR 9UgCpNT1;ACTl <br />rHAT !N THR P@1t60RMANGE 4F Tpl{i: WORfG FOR WHICH ThIIS. PERMIT 16r IS�eUED, I SIUILL EMPLOY..P/�ER90N8 &Ut3.}Et:l' TO WO}2KER'$ COMPENSATION <br />re nh��PORHId.•...._ % A l � w.fl.,r� it/i1A��wA�iC nein ✓�'"�7?' �'M <br />BILLING INFORMATION: <br />to be billed ibr additional EHD staff tims expanded beyond permit payment coverage per tank. if <br />Indiolts the r"ponsible party It Applicant, ®.g, property owner, the party must aG1mdW(adQ9 flits <br />the party deoignated baiow is different than the palmt o <br />responsibility for the billing by signature and data below. tr <br />NAh(E!1��� �— TTTI.e i�AiY1�.('" PHONE <br />�� <br />jjH2300*a (rzvlsed 12-11 -15) <br />Pr job Contact Telephono 41 <br />F <br />EPASit" <br />Phone #itR <br />Wo <br />' <br />Fsality idgmd 1►jiliri <br />`� <br />'2U <br />I <br />Addfr <br />i <br />cybas Strait <br />Phone # <br />' <br />Y <br />t1yyrleripperakar ' <br />Pliers# CISaG <br />d <br />Contractor Name <br />CALIo# "' <br />, <br />Cl6ai7 <br />14 <br />Contractor AddreSs 1(31) t <br />Work Camp # <br />R <br />insurbr <br />(=xpiratlan taata '� <br />C <br />T <br />IGC Technieiaws Name <br />Expiration Date <br />10 <br />RChemicsis <br />tee Installer's Name <br />Stored Curren* <br />Date UST <br />installed <br />Tank Syatam work area <br />Tank Size <br />7 <br />A <br />N <br />K <br />QApprovedApproved with conditions <br />Disapproved <br />P hment With Conditions) <br />A pate <br />M Plan Revlewers N$ <br />�PPLIGiINT NNST PERPeRM oRlc IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />aYAi>; tJ4YY5, AND RU4.)=3 ANt] RFAULATICNg t>g eAAi <br />NG $1GPIATURE CERTIFIES THE FOLLOW1Ntk I CBRTtFY <br />FOL <br />7HRr 1NGRK FdR WHICH TliFS PERAAn 188iJErti, I S11P•LL NOT E MPLQY ANY PERSON IN SUCH R NIi1NN@R AS T4 BGCOME gU8JE0 r TO <br />oA4UlN CdUNTY, ERF RONME Rt M9EtsLTN p>rpAFt7MAENT. OWNER OR LICENSED ADiNTB SI(ANATURE ceRTISES THE VI! eS TO 9 OGf2Tl <br />pERF4RMAMICE 0 <br />�p}q(�'B GgMP6N6AT1Oiti1 rAWS OF CALIFORNIA.' OO�pTORS HlR1NG QR 9UgCpNT1;ACTl <br />rHAT !N THR P@1t60RMANGE 4F Tpl{i: WORfG FOR WHICH ThIIS. PERMIT 16r IS�eUED, I SIUILL EMPLOY..P/�ER90N8 &Ut3.}Et:l' TO WO}2KER'$ COMPENSATION <br />re nh��PORHId.•...._ % A l � w.fl.,r� it/i1A��wA�iC nein ✓�'"�7?' �'M <br />BILLING INFORMATION: <br />to be billed ibr additional EHD staff tims expanded beyond permit payment coverage per tank. if <br />Indiolts the r"ponsible party It Applicant, ®.g, property owner, the party must aG1mdW(adQ9 flits <br />the party deoignated baiow is different than the palmt o <br />responsibility for the billing by signature and data below. tr <br />NAh(E!1��� �— TTTI.e i�AiY1�.('" PHONE <br />�� <br />jjH2300*a (rzvlsed 12-11 -15) <br />