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• 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 458-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMfT TYPE BELOW <br />UTANK RETROFIT UP*nr4G REPAR/RMORT I h fnr RFPA{R <br />F <br />A <br />I EPA Site # <br />Project Contact & Telephone # - - - - <br />C <br />Facility Name S <br />Phone # - 1 <br />LAddress <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator i <br />�y ` <br />Phone # 02®<' Ll (4 <br />Co <br />Contractor Name <br />Phone #'Ro') (o _ <br />N <br />T <br />Contractor Address <br />�) CA Lic # Class " <br />A <br />Insurer lU <br />,irk &,r; # �,;.� L -- <br />C <br />T <br />i an <br />ICC Technci's Number <br />Expiration Dale <br />R <br />ICC lrtslaflWs Certification Number <br />Expiration D3tB <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />CurrentlylPreviousty <br />Date UST tnstatied <br />T <br />A <br />u <br />K <br />P <br />LI+PPmved <br />ved with conditions UDisapproved <br />L <br />Attachment With Conditions) <br />N <br />Plan Reviewers Name � ` - <br />Dais <br />APPLrAt+fi MUST E'ETRFClH M.AL L MCOW KAOCORnAWX-Mfi7 "SAN Jg4QL IN WUtdTY. QRPN4499 .-S JI : AN RIAES AND RE%AARONS: OF SAN <br />"CM COLRIJTY, ENVIROt6l WAL HEALTH DEPARTMENT. OMER OR LJC84SM AGENTS SIGNATURE C EITFU IES THE FCLLOVJ NG: 'H CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FCR WHICH THIS PERW tS ISSL� I % L NOT EMPLOY ANY PERSON IN SUCH-! A MANNER ASTO BECOME SIJSJECT TO <br />1102ICER'S 11*1 4SATION LAWS OF CALIFORNIA' CONTRACTORS HIRMOR SL1E100NTRACnW3 SIGNATURE CERTIFIES THE FOLLOW9,IG 'I CBMFY <br />THAT IN THE PERFORMANCE OF TimWOF2lC WHICH THIS PERMTf IS ISSUED. I SHALL EMPLOY PERSONS su&ELT TO YN RKEFrs COMPENSATION LAws <br />OF CALIFOWSA' <br />APP --�� _ T. <br />BILLING INFORMATION: <br />zl� <br />Indicate the responsible party to be billed for additional EI•ID staff lane expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must aclmowledge this <br />responsWity for the baling by signature and date below. <br />NAME �\ �^i V,1mw'� 71TLEC V PHONE # <br />3� <br />EH23DO38 (revised 8MM) <br />