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• <br />0 <br />NVtRONMENTAL HEALTH EPARTMENT <br />SAN JOAQU N 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 />THIS PERMIT EXPIRES 90 DAY'S FROM THE APPROVAL DATE INDICATE PERUIT TY''M BELOW <br />L AmK REIROFTT LImNG REPAZ/RE mom i__6)c REPAWJRE7ROAT <br />F EPA Site # Projed Carrtasf & Telephone # <br />A <br />C FaclTii)rdress Name Phone # <br />L <br />I Ad <br />TI VIJ Cross Street <br />Y I OwrrerlOpetator Phone # <br />c rC-nt' <br />N Phone # <br />0 <br />T Act s, In CALic# Cuss3s P1% <br />R • WorkComp# <br />Aon PA ftL. <br />Tcian's CechTiCation N,;X r WOZ05 Expiration Date <br />R1CC kmtaWs Cer#i cation Number Expiration Date <br />Tank m # Tank Size Chemicals �� CiaAe UST Installed <br />rrenwreiioT <br />A <br />M <br />I K I f 1 I <br />P ��PPtavedpproved with condition UDsappmved <br />L (See 'Attachment With Conditions) <br />A ,n <br />N Plan Reviewers Name�-.� — 1 �� /k'ii.`� Date <br />APPUCANT U1 PERLBiMKX YCxACCXRry- SrATEk-AM !j <br />OydCOUNTY,Fl7FAb9 :CF SNet <br />ENVIRONMENTAL HEALTH CEPART81BJ1: OY MER OR L K24SM AGENT'S SIGNATURE CER I F1E5 THE FOLL0043. 'I CERTIFY THAT IN <br />THE � OF TEE WORK FOR WHCH TM PERMIT' IS ISSN 1 SNAIL NOTEMR.OY ANY PERSON W SIKH A MAN4ER ASTO BEC OME S"E C] TO <br />VK?FZKER!S COMPENSATION LAM OF CALIFOFaW CONTRACTORS HIRWOR SLEX)ONTRACTING SM47LJRE CERTIFIES TETE FIOLLOWM 'I CERTIFY <br />iTIFY <br />THAT IN THE FEWQRMANCE OF THE WORK FOR V"CH THIS PERMIT IS Emm. I sHAL L EMPLOY PERsatS sLexCTTO WORKG2'S cmna SATjoN LAWS <br />CF GAMIC RN - <br />s 1 <br />BIWNG INFORMATION: I <br />Indicate the responsb a party to be billed for additional ERD staff fine expended beyond permit payment wverage per tank- if <br />the party designated below is ML -rent than the permit applicant, e.g. property owner, the .party must admow1edge this <br />r+espon J' for the billing by si abuts and date below" <br />NAiJ[E TITLE ""v \ 4 ��lVC 1 _PHONE #_� <br />ADDRESS K 6) <br />EH23DO38 (revised 8/8 S) <br />1 <br />