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JAN-3-2002 11:24A FROM: 70:19163724873 P:2 <br /> May 07 07 11 : 25a JP Pe leum Service 9163724873 P.2 <br /> ENVIRONMENTAL HEALTH EXPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 304 East Weber Avenue,Third Mor,Stockton,California 95202 <br /> Tel e.-(209)468-3420 Fix- (M)4W3433 <br /> APPLICATION FOR UNMRGROUND STORAGE TA14K RETROFIT OR PIPING REPAIR PERMIT <br /> TI*S poRmiT FXMSS so DAYS FROM THE APPROVAL DATE. NOCATE PERMITTYP15 etLOW: <br /> )TANK RETROFIT EiPjPING RC-PAPjRI[TR0FIT [jUDC REPAIPiRETROF11 <br /> - <br /> F EP -T.-- <br /> .A Site X I project Contact&Telephoine# <br /> A Phone S' J& <br /> C Favi it Narmm <br /> L <br /> cross street <br /> 'y ownerloperati; 3-6917 <br /> Contractor N Phone NFI& 75W? <br /> N ContracorAddress '(e- cA tic 0 class Pr <br /> T <br /> RIp x gel <br /> A In9urgr e^-7 -------- <br /> C ICC Techni6aWs Cerff=jon Number ExpirllfiDn Date <br /> I R ICC Insts <br /> Tank ID 0 Tank Size ChemicalS Stored Date UST IrWahed <br /> Currenoy/Previously <br /> 4 <br /> T *4 t- <br /> A <br /> K ----------- <br /> ii d <br /> P -AppraveO UIpproved wKh con dkions <br /> L. (S"Aftat-WITWO WM CWIdi§OnS) <br /> A 11 01 <br /> N 11ho Date Pian Reoewers Name........... <br /> APPUCANT WST PERFORM ALL WORK IN ACCORDANCE W17"SAN JOAOLM COVMY O"DKA`N='STA?aL.AW%AND RUES AND F*GULATOW OF SAN <br /> JOAQUIN COUNTY.ENV11RON_A0WAL HEALT114 DEPARTMENT.OM46R OR LICENSED AG&VrS SMATPR RE c5WfM THE FMLONW--,: 'I CERTIFY THAT IN <br /> 71.*P0W0F40ANC6oF fT �KFOR WHICH THISPERMT r4 ISSMD.I SHA"NOT eMPLOY ANY PERSON IN R4FtA WAWR AS TO BFCOMF&SMACT TO <br /> WORKEn OF 1FOFWA" coNTAACTOreS PRIFING OR SUBCONTRACT04 SIMATURe CENTL94ES THE FDU-OWM: ICERTIFY <br /> TT AY IN TW%-GZWF FOR WHICH THIS P5R�IIT IS ISSUED,I SMAU EMPLOY PER WO SPR TO WORIIERS COMPENSATION LAWS <br /> OF CAUFOR77NIA.' ;,171P 7 <br /> Daft <br /> BILLING INFORMAIO <br /> Indkwe the resporrAble PartY to be billed for add&"al FWD it*m e4wded beyond permit payment DoVaWe per tank Of <br /> the party asignsied below is dderent than the Permit appkent, e.g. property owner, the p" must adge this <br /> respons"I far the b.-.. by 3.grotuM and a be <br /> —TITLE— -PHONE <br /> ADMORESS <br /> SIGNATU <br /> JAN-3-2002 THU 11,� SAM 10: PAGE:2 <br />