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0 IR <br />ENVIRONMENTAL HEALTH DEPARTMENT <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 DAYS FROU THE APPROVAL DATE INDICATE PERI rr TYPE BELOW <br />UTANK RETROFTr UPIPING REPAWRETRORT Lk= REPARMURORT <br />F <br />I EPA Site # <br />I Project Contact & Telephone # <br />A <br />C <br />Facility Name <br />Phone <br />L <br />AddressCa <br />C15ciftO <br />I <br />T <br />Cross Street <br />Y <br />OwnedOperator <br />Phone <br />C <br />0 <br />Contractor Name <br />Phone # <br />N <br />T <br />Conlrac4or Address <br />CA !ic # <br />Class <br />A <br />Insurer <br />%l I ' <br />work Comp <br />T <br />ICC Tecfmician's Certi6rcation Number <br />J <br />Expiration Data 1-1- 610 <br />O <br />R <br />ICC Ins3aws Certify Number tion Numb <br />Expiration Date -- <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Dale UST Installed <br />Currently/Previously <br />T <br />A <br />w <br />K <br />withconditions UDisapproved <br />` <br />ffUApprovedproved <br />( cturlent Wifh Conditions) <br />iewers Name <br />Date <br />APPLI <br />AW MUST P_ERFL1W.ALL.v4ORIcLnt A <br />le3Tf� sAN.1D9ptltal ...: L116II�ICES..STJITE..�1Sn�S ;Ae[) BL E,S AM RSP -4A1 3W QF SAN <br />30AOUN COJNTY, EW ROWAENTAL HEALTH <br />OMER OR 11MISED AGENPS SIGNATtJRE CERTIFIES THE FCri LOMMG- 'I CER71rl' THAT IN <br />THE PERFORMANCE <br />OF THE WORK FCR WHICH THIS PERW IS ISSUEQ, I SHALL NOT ELMW ANY PERSON W SUCH A MAMER ASTO BECOME SLEUECr TO <br />Vj0Faa3r'S cC&f E3mTKw LANS OF cmoKxwdA <br />CONTRACTORS HRMOR 9JBD NTRACTW. SKMTURE C ERTFIFS THE POLLowt,1 - 9 C SZnFY <br />THAT IN M -E PSFUMMyANNC�E�O�F�THE V`Y1p,W FOR MCH THIS PERMrT IS IS'SrLM. I S HALL EMPLOY PEiZSON.S SUB.ECT TO VYO7RKE FrSS COMPE RSATION LAWS <br />--L , <br />4 it I <br />App�tsSgr-h— <br />�I T 1 1 W WIK <br />Tdte j ,u <br />BIWNG M RMATIW. <br />Indicate the responsible party to be billed for additional EHD staff fine expended beyond permit payment coverage per tank_ if <br />the party designated below is different nt than the permit apprk2rk e.g. property owner, the .party must admowledge this <br />responsibi['rty`fo-r the billing by signature and date below. <br />NAME Q % Tc) ebCffX- <br />nonRFss <br />EH23D038 (revised BMW) <br />