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0 <br />• <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, TLird Floor, Stockton, California 95202 <br />Telephone: (209) 469-3410 Fax: (249) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />TMS PERMIT EXpIREs 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW <br />k L ____ _ � �z�wr DrDA1Djar7 r9 -1T UDC SDC REPAWREI-RORT <br />APAlicartse --- <br />BIWNG I MATION: <br />indicate the responsible party to be billed for additional EHD staff fine expended beyond permit payment coverage per tank_ if <br />the party designated below is different thanthe permit apprimrit, e.9. owner. the party must adawwJege this <br />PrdY <br />forres�n <br />7Sol <br />imp � date below.-- �//ONEf-�Wl <br />•� 4. <br />EH230038 (revised M06) <br />USUM1R Kt 1 KUN f .�.............. __.._ .. ___ _ . <br />F <br />EPA Site # Project Contact 8. Telephone # <br />A <br />F/ <br />Facility Name i/ <br />L <br />Address <br />I <br />Cross Street <br />T <br />Y <br />Owner/Operator <br />— <br />Phone # U <br />C <br />Phone # <br />contractor N <br />O <br />N <br />Contractor Ca !ic # Class,4 0 <br />AInsurer <br />Work Comp # <br />ICC Technician's Certification Number Q( <br />Expiration Dale <br />T <br />RJCC <br />Installer's Certification Number <br />irate <br />Tank !D # <br />Tank Size <br />Chemicals Stated <br />Currently/Previously <br />Dale UST Installed <br />T <br />A <br />N <br />K <br />z-I+PPmved i44ppmved with conditions LIDisProved <br />L <br />(See Aitac hwnt With Conditions) <br />A <br />� <br />� <br />N <br />Plan Reviewers Name Date 3I 07 <br />APPUCAW MUST PERFORM.A-L MOM K.a -fel T14-�AD1.fgApL +{C0UWY. tnIJCE� -S[ATE LA1t�S ns[�sLJt€s.AGD_ReGIA�►Z :OF SAnt <br />ENViF20"AE1%TAL i EALTH DEPA� OM4ER OR LIMISSM AGBC S S"IATURE C8U IES -nC FOliO4R C 'I CBMN T14AT IN <br />TO <br />"CYAN 0Ot3E0Y. <br />THEpEpj=0RMANGEOF THE IKORK FCR vM 4nj THIS PERMIT IS , i SHALL NOT EMpLOy ANY PERSON IN S)C H A MANNER AS TO BECOME SUBJEGf <br />SKsNATURE CERTI IES THE FOLLOY44G 9 CERTIFY <br />VVORKER'S COMPENSATIONOF CALIFC7RNIA CONTRACTORS t�RINGCX2 SUEIOONTRACTBJC <br />THAT IN T! -E PEF IE YWORK FOR WIWC H THIS PERMIT 6I SNAIL EMPLO/YyPt SJB.ECr TO V40WJ3ZS COMPENSATION IA NS <br />CFcAUFORraA- � <br />APAlicartse --- <br />BIWNG I MATION: <br />indicate the responsible party to be billed for additional EHD staff fine expended beyond permit payment coverage per tank_ if <br />the party designated below is different thanthe permit apprimrit, e.9. owner. the party must adawwJege this <br />PrdY <br />forres�n <br />7Sol <br />imp � date below.-- �//ONEf-�Wl <br />•� 4. <br />EH230038 (revised M06) <br />