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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone:(209)468-3420 Fax:(209) 3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TMtS PStMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE,94WAIE PERMIT TYPE BELOW <br /> UTANK RETROFIT L-6ox,REPAm,,E rr Llmc REPAiR/REiROFrr <br /> F EPA Site# Pmjed Canted&Telephone If <br /> A <br /> Eac�ity Name Phone# -`S <br /> IAddress <br /> L <br /> I Cross Stmt <br /> T <br /> Y o ne# <br /> OwnerlOperatar <br /> cContractor Name Pbne# <br /> N contractorz; # cisU7, <br /> R Insurer Work Comp# '7 <br /> An <br /> JIE A <br /> IMP T icc Tmmirian s Number Expimi on Data <br /> Ricc installer's CefffKafion Number Dam <br /> Tank ID# Tank Size Chernwals Stored [Yate UST irk <br /> Currently <br /> T <br /> A <br /> w <br /> K <br /> �Ap,.d%cbnditio- u�apMved <br /> � L�APproved (See ASacdnnent With Conditions) <br /> NPlan Reviewers [)afa <br /> ( C� <br /> ppp�CAtrllpRil.IILL.VSI�RKL►L ..._.... ..._. ._..__. <br /> JOAOUIN COUNTY,EWJ AL HEALTH OEPARTMt3 M O WIER OR Lx8jSED ACENI S SIC TikiE.0 THE FalaA aaa: '!CERTIFY THAT Bd <br /> THE pgRFoRMANCE OF THE WORK FCRV&9C H THS PERMIT'IS ,i SHALL NOT EMIPIAY ANY PERSON <br /> S�NATIIRE CA MANNER <br /> THE TO BECOMEFOLLOV* - aIECT'I�Y� <br /> VYORKBtS TON LAMAS OF CALIFORNIA coNiRACn cws AOR <br /> THAT IN THE OF THE V"M FOR V"CH THIS PERMIT IS ISSIJED,I SHALL.EIS!AY PERSONS S 1BJECr TO VYORKERS COMPENSATION LAWS <br /> OF CJa• . <br /> Dale <br /> Appikarts 9L/ <br /> BIWNG RMATION: <br /> Indicate the responsible party to be bitted for additional EHD staid fare expended beyond permit payment Coverdge per tank if <br /> the pally designated below is dd€ererlt than the permit the e.g. property owner, party must admovAeop this <br /> responsdAty tier the bif ing by signaftue and date below_ _ <br /> NAME / ME t <br /> ADDRESS <br /> SIGNATURE <br /> 6423DO38(revised 80M) <br /> 1 <br />