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FROM FAX NO. r. 18 2009 01:50PM P1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> boo Last Main Street,Stockton,California 95202 <br /> Telephone: (209)4683420 Fax:(209)460»3433 <br /> APPLICATION FOR W99&QROUN0 STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TMiitEKP1tiE81® Y6"OM Tt APPROVAL*Arf. INDICATEPBRMITTYPE GROW <br /> Q TANK RI°'I" FIT C�''PI REPAr OFIT ❑ UDC REPAIR/RETROFIT ❑ COLD sTARTrEVR UPGRADE <br /> € EPA Site# Project Contact Telephone# g 6 33S <br /> Fatflty Now Fhone <br /> L Aadreee 1-4>C)� F <br /> I Cress street <br /> Y e paietor .. ° C�'.Q!SPt tV Phtxie illZ�"--?O$— <br /> C N <br /> conrraDtor p* Sfn Raf t Phor,a#. -y�aY <br /> N <br /> T ConlraetbT Addrnas t5r0 Cr4 UcAt.�f�� CId9$(r <br /> ry !� <br /> R Insurer WCrk CorTtp t A <br /> C t0C Techhician's Nana Expiration Me <br /> R IGC Installer's Name Expiration Date <br /> Tank system work ores Tshk Stte Cham axis Stored CwTently Date UST <br /> (In.V WOO 0011W bt 9Sdcdll WW.UCC M4 91C) Installed <br /> E A <br /> K <br /> P ApprOVed ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment Wigs Conditions) <br /> IA <br /> N Plate Reviewers Name Date <br /> kPPJCA r.MJST PCRFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY OROINANMS,5TAT6 LAWS,AND FI6%W AM RACWTIO14 pr.¢RN <br /> ,10AQVIN COONTY,ENVIkONMENTAL HEALTH DEPARTMENT,Q%WV OR UeENSEL AaENrs siomf JRs CarITIPIEs THE FOLLOINNG: '1 MTMY THAT IN <br /> THE PERFORMANCC OP TWK FOR\A"C14 THIS 0ERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PM80H IN al"A MANNER A$TO 13T41014 51JeJECT <br /> TO aYORKGR"9 6 OM R+CTOR a RmNa On OU@CDNTRACTrN4 SIGNATURI Osancrs T►�FDLLoIAINC: "t C5R`1FY <br /> THAT W THE PERF AN OP a V�IK FOR lA�I.-H ;RMIT it IS€USO,I SHALL EMPLOY PERSONS SUNURCT TO WORKER'S COMOGNSATION LAVVG <br /> ar ek;u+OW'1A• <br /> r <br /> AnHIP�g)1'8 9t 6WIE ..�� - <br /> S /1910 <br /> BILLING INFORMATION: � <br /> indicate the responsible potty to be bird for eddktonal I:HD staff time expended beyond permit payment COWSP per tank. If <br /> the party designated below Is dlFlerent din the pertnit applicant, &g. property owner, the parry must acknowledge this <br /> responsibIlity for he billing by sigi`WUM anti gnat®Wcw� <br /> NA _ 4rM NoR dd LaLrIJ�� PHCN= .® A _ Zof <br /> ADD <br /> Re53 0 t0 I 6A/A CJA Pt '94 W. C- C h -p�1 7 <br /> A q <br /> GNA?URE DATE__ <br /> r EH23t7031!(r®v18sd OZl2 _ <br />