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ENVIRONMENTAL <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TMS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE 94MCATE PERMIT TYPE BELOW <br /> UTANK RETRORT UPIPING REPARIRETRORT UuDc REPAtRMETRORT <br /> F EPA Site# ProjectCantas t&Telephone# <br /> C Facility Name Phone# 6' <br /> LAddress <br /> I Cross Street <br /> T _ <br /> Y ownedOperator I Phone# — <br /> oContractor Name Phone# <br /> N Contractor CA Lie# Class AA/I <br /> T <br /> R Insurer C Work Comp# <br /> A <br /> T <br /> T ICC TeChniaian'S Certification Number Expiraton Date <br /> O <br /> R ICC ksstalt s Coertilication Number Expiration Date <br /> Chemica <br /> Tank ID# Tank Size is Stared we UST installed <br /> T <br /> A <br /> N <br /> K <br /> P L IApPmved ,,ed w-M conditions UDisapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Na Date <br /> [APPPRUICAtW0 k*PU-ST P_ERFORM.ALL 1dIORlC. <br /> JOAQIaN COUNTY,ENVIRONMENTAL H OEEPARTMENT.OV N£R OR L1COISED AGENPS SK;1ATURE CERTIFIES THE FOLL0Wa43: 'I CERTIFY THAT IN <br /> THE PERFCRMANCE OF THE WORK FOR Y1R 9CH THIS PERMIT IS ISSUED.I SMALL NOT EMPLOY ANY PERSON IN SUCH A MA ASTO BECOME SUBJECT TO <br /> WORKER'S LAWS OF CALIFORNIA.' OONTRACXFrS HRW OR SUBCONTRACTING SIGNATURE CERTIFIES THE 'I CERTIFY <br /> THAT IN_TT•E OF THE YVORK FOR WHICH THIS PERMIT E I sem,I SHALL EMP{OY PERSONS SUBJECT TO TION LAVYS <br /> OF CAIJI AM <br /> Appkarts rifle <br /> 8lWNG RMATION: <br /> indicate the responsible party to be bred for additional EMD staff tine expended beyond permit payment coverage per tank. If <br /> the p esignated below is different than the permit applicant, e.g. property owner, the party must a this <br /> far the billing bysignature and date below. <br /> NAME ®' TITLE ONE# <br /> 6 <br /> ADDRESS <br /> SIGNATURE }^ <br /> t -(j <br /> EH230038(revised 818M) <br /> 1 <br />