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Apr 18 13 12:15p CalPhase (408)292-2052 p.2 <br /> Apr. 1U. 1013 1: 16YM l?qoaquin Uunty iVo, U511 Y. 1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> . SAN JOAQUIN COUNTY <br /> 1868 E.Hazelton Ave., Stockton, Callifomia 95205 <br /> Telephone: (209)465-342a Fax: (209)468-3433 <br /> APPUCATION FOR UNDERGROU14D STORAGE TANK <br /> RETROFIT ORPIPING REPAIR PERMIT <br /> THIS PERWEXPIRES1W DAYS FR0MrMRAPPFt0vAL0A'tP_ <br /> QTANK REfROM XPIPING REPAWRETROFIT 0I b REPAWRE ROFIT U COLD STARTIEVR UPGRADE <br /> F FPA Sire# Frriniect�orltaCl$T ttone N '� <br /> Iv FatUI(Sy f98mia moi ,• Phone ti <br /> tAddress "'�- � �.C.S•�•• �.�G � ----- <br /> T Cross Street <br /> DWnerJC7pordlor G f" + C f � � Phone A {j . <br /> N cw4ractor Name C ! Phane it 7U <br /> Corwramr Addre <br /> R ss <br /> aInsurer u Set o ce } Wark Comp fl 467 --ot-01 <br /> Y I C technicians Name <br /> o Expiration Date•• 1— 015 <br /> R ICC Installer's Nar71s Expiration Date <br /> rank system work area <br /> 61Mrow.VW u:.ap; Tank Size Chemicals Sk nd Currently OAte UST <br /> n e sr vor�gaumd ne tssx <br /> 4rtsi�ltico <br /> N <br /> rt <br /> P �� Ap"vea proved vwlh condhions � Disapproved <br /> A ( AttmChmenl With oondiugns) <br /> fv Mari Reviewers Name <br /> f Dtste <br /> .PPLICW MUST PERFQRM ALL WORN iN ORpANCE irlfPH$AN JOA(1LON COUNTY ORDINANCES.STATfi LAWS,ANb KLAXS AwC ri�Y O AAOt4$of SAN <br /> UNTY.HEPER ORMANCecl J OF RWMEALDEPARYMENT.TOWNER OR LICENSFO AQWrS VGWAYt)RE4ERyWIES THE FOLLOWING: 'I�tRnFY7kAT Al <br /> EP FofiMAkCE OF THE wOrrK FOR N(MACH THS PF<RrfiT IS L&9UED,1 SHALLWarr EMPLOTANY PERSON IN SLCH A WAW ER A$TO BECprNE Sl1KdECT Tp <br /> tlrEA'S dDrlPEALSRTION LAWS OF CALJF ! CoftjrRh"0",S HIMAG OR 5UBCONTRAMNG SXWA'TUAr CERTIFIEER ArS'YHE POMCOW' 'I C6UTo <br /> MFy <br /> r14AT INTNB PFAFt>RLtAt EDF 7 wpRr(f HIC 7HfFYERtitrf E6 1S51JE0.1 SH PER80NaSU8JEG770 WORKER'S OpMPENcSAYloN LAWS <br /> F CJiLIrOR2M' <br /> I � o>u TIII ,. D,� r� Z�c✓ <br /> BILLING INFORMATION <br /> N tare me responsible party to be 1311ed foraddltional EHQ staff line expended beyond Permit payment coverap per lank. if <br /> 0a early designated below its different than the permit ZPPACi rl, e.g. Arcperly owner, flip party must acknowledgTri s <br /> -wponsd►iN(y for the billing tq Signature Sfrld date below. ! e C <br /> fylfV w' yi G �; �TtE <br /> L!%(' <br /> DRESS_2 <br /> $iGNA7URF------rr- I � ,.... QA'rtr,_._,_ <br /> £N2 (M9 iaed TfJW, <br /> 2 <br />