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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SACT JOAQ►U M COUNTY <br /> 600 East Main Street,Stockton,Caigfoirala 95202 <br /> Telephone: (209)468-3420 Fax- (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRIS 1W DAYS FROM THE APPROVAL bare. II nATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRE"PROFIT Q UM REPAIWRETROFIT Q GOLD STARTe-R UPGRADE <br /> F 1:0A 3;tn a <br /> A Project Contact&Telephone# & <br /> c Facility Name F V phone# o <br /> Address - <br /> - <br /> Tcmas street <br /> Y phone#1-�6 ftn- <br /> c Contru tir N ' <br /> N u' Phone 45�� - ,��• <br /> T CPnbsc orAifdreBc S t �t� ,�7 Lc"a S - CA Uo#, LSC ,IQ Gas <br /> R Insurer - <br /> A t-^ - � >�1�- Work tromp <br /> T ICC'redhhldM's N.. <br /> F.xpiretlon Date <br /> A ICC Installers Name <br /> pxplydtlon Date <br /> Tank system work,rap <br /> p,e. Tank t3tze Chemicals Stored Currently Data UST <br /> e�pping rtnup,et Ieak delFxtor,tJDC tnl Atr,} installed <br /> err <br /> T <br /> A <br /> � <br /> Nyy (��1 <br /> 'l + <br /> P ❑ Approved <br /> L pproved with conditions onditions ❑ Dlsapproved <br /> (SEB/�fl, t"C>0n3) _77rA C� <br /> N plan RaWtwvers Name 1 i� s <br /> �f�ooc <br /> 44 <br /> APPLICANT(MUST PIRPOW ALL yup IN ACC NCE TH SAN JOAQUIN COUNTY OROINVMS,STATQ LVA AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,t:MMONMCNTAL HEALTH OEPARTMWT,OWNER OR LICGN9jjO AGEM`s SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THS P6RFORMANGE OF THE K FOR WWtOH T1413PE>zMrr IS ISSUED,I SHALL NOT 9MPWY ANY PIERSON IM SUCH A MANNER AS TO IBIECOM4 SUBJECT <br /> TO WORKER'S COMPEN§Ar M W3 OP CAU ORNA,"0ONTRACTOR'S HIRING OR SIJ�QdNTM0T(NQ 81ONATURH GERTIMES THE FOLLOWtNQ: "18t•rtYiFY <br /> OFIN THE POROTtAA H TWIS PERMIT 1819SUE0,!SHALL EMPLOY PeRSONS 4UBJEOT TO WORKER'S tOMFIEENSATION LAWS <br /> OF CALIFORNIA-"bt" ' <br /> M bb8'A SI Nu 1 % <br /> Tice 4+no Z--C� r <br /> ILLIN13I FO MAIrl <br /> Indlaate the A&SPOnSIble party to be billed Tor addltkrna! EHD staff time ex nded be W Permit payment covers e <br /> the party deskjnated balow Is diffewt th the Pe y p 9 Per tbnk, H <br /> permk aPPllodtlt, e.g. property owner, the party must adtnowfedge this <br /> respanslbility for the billing <br /> /by signCture and <br /> I�TITLEJ�IZ �PHONt?�F <br /> ADOPESS ' <br /> SIGNATtlRI_ A+ <br /> DATE 313/a' <br /> E}1234038 Irevlsed 0?J2tSi09) ���� <br /> 1 <br />