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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)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> TM PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT BELOW: <br /> UTANK RETROFIT UMPING REPMAIETRORT UUDC REPAIR/RETRcn <br /> F EPA Site# ProjectCantact&Telephone# `�P'�' <br /> AP <br /> hone#c Facility Name Y <br /> IAddress G <br /> L <br /> Cross Street <br /> y OwnerlOPeratar Phone <br /> C Contractor Phone <br /> T <br /> contracto Z <br /> R InsurerWork Come# l!7 <br /> A <br /> T b°r'Dal <br /> ICC T 's Certification Number <br /> R icc instalws certification Number ExPi�atiorl Date <br /> Tank Size Chemicals Stored Dale UST insbdw <br /> Tank ID# CurrenthdPrevioccsly <br /> T <br /> A <br /> N <br /> K <br /> P r-riPPmved L Av mved via conditions Lbisapproved <br /> L (See Attactmrent With Conditions) <br /> A A/a-x � it)lo N Plan Reviewers Name - �� <br /> APpLICA 9 MUST P_ERFOMAtL WOE LN..AO WTI Snotjgq q]lN=WTY.oRplkl 1C�s.,.STATEt1 WrJ ANIXR1 R€s.ASB_RE�GIAATtg6�tS;c7E SMI <br /> "CON COI/NfY,EW AL HEALTH CEPARTMENT.OWNER OR UMISED AGENTS SK;NATURE CERTIFIES THE FOLLOMIG 'H CERT"THAT W <br /> THE PERF-0RYSANC£OF WORK FOR NMICH TH<S PERW IS tW"t SFIAHL NOT EMPLOY ANY POISON W SUCH A YX4"ASTO BECOME SLE ECT TO <br /> ylpR}{g2S LAWS OF CAL A' CONTRACTOR'S FIRM OR SIC4 ATURE C RTW ES THE fOLLOW@�K� 7 CERTIFY <br /> THAT IN T};E OF TFfE.vYORfC FOR WFBCI{THIS PE32L1IT IS ISSUD.I SHALL EMPLOY PERSONS SUB.ECr TO WCX�CERS COMPENSATION tJI1AfS <br /> CF CAL<FORP71 <br /> APPS <br /> B!L!_tNG tNFQRMATION: <br /> indicate the responsible Party to he bitted for additional EIiD s f ne expended beyond permit Payment coverage per tank If <br /> the party d ' nated below is different than the permit e.g. property Owner. the Party must � this <br /> responsibii' forthe billina by sgnahr an� is below. a <br /> NAME 11 <br /> ADDitI=.-3 <br /> SIGNATURE <br /> EH230038(revised 818106) <br /> 1 <br />