Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQU N COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone:(209)468-3410 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT E"zFs go DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELONG <br /> UTANK RETIZORT UPIPING REPM61EMORT U=REPAIRIRETRR�OR"T <br /> F EPA Site# ProjectCantact&Telephone# <br /> C Facility Name ly Phone �/oL <br /> IAddress <br /> T cross street rbW 9 <br /> T Phone# 2 <br /> Y OwnerNperator <br /> C Contractflr Name Phone# D <br /> N contractor ss �' � CA lic# <br /> �l2 <br /> R Insurer VVork Comp# Q 9 <br /> A <br /> TICc T . Number F3cpiration Daly <br /> R Expiration InstaWs certification Number <br /> tifi <br /> Tank Size Chemicals Stored Dale UST hnstalled <br /> Tank ID# Cnrrently]Previoush <br /> T <br /> A <br /> w <br /> K <br /> P f JApproved hrvmved with conditions UDiSaPPfDved <br /> L (see A.Wadirentvft conditions) <br /> A <br /> N Plan Reviewers Name Dates {f <br /> pppiJCAt[C1dl1ST> �fRM.ALt1i RKLnta .felTiH.SArIlaaCxlNtCAcmIIY, tA6K S..SiATE111Y :Ae > - �aaMFY:14SAN <br /> JOAC M OGl(A" eN Rmzm34TAL HEALTH TEpATRrimf.6AER OR LrmsED AGWM sG ATukRE c8uu:cs THE FOLLOww: 9 CERT�Y THAT MI <br /> THE PERFORM0 CE OF THE V40W FOR VCH THIS PERMIT IS ISSr1EO,19-ML NOT EMPLOY ANY PERSON IN SUCH A UAN BR AS TO BECOME SUBJECT TO <br /> Wafaa S CCXJP 8SAT1ON LAWS OF CALIFORNVI' CONTRACTORS HIRING OR amcoNTRAcaw.SICyNA uw c6 nwiES THE FcuotRNG "1 CERTIFY <br /> THAT IN THE PEWORMANCE OF THE VV,-W FOR V*9M THIS PERMIT IS ISSUED SWILL EMPLOY PMS SUB.ECT TO WOWS RS C0MPERBSAT1ON LAWS <br /> CF CALIFORNIA." <br /> APPficarts a TAfe Dafle <br /> BILLING INFORMATION: <br /> indicate the responsible party to be billed for additional E�D s lane expended beyond permit payment coverage per tank. If <br /> the p hated below is different than the permit e.g. owner, fhe .party must acialowle�e this <br /> apo for the bitiigg by s" and date below. <br /> NAM <br /> ADDRESS � • .. <br /> SIGNATURE <br /> EH23DD38(revised 8/aMG) <br /> 1 <br />