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Sep 23 2008 10:01AM Sluraker Construction 951-788-7089 P.1 �/il <br />I Vy <br />Ric rr,�J <br />i�./ <br />ENVIRONMENTAL HEALTH DEPARTMiur <br />SAN JOAQUIN COUNTY SEP 2 3 2008 <br />600 .East Main Street, Stockton, C2.6rornia 95202 SAI/ "IOAOUIN C <br />Telephone: (209) 468-3420 Fax: (249) 468-3433 E T� 0- CAL T Y <br />H MENT <br />UEPAf I <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR W9RMIT <br />TK* PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />DTANK RETROFIT 11PIP01IG REPNRRtETROFIT F-11 Xx` W=PAJPiwerra41e1r <br />FA <br />EPA Site # Project Contact & Telephone # OPO ft79�1 <br />Facility Name �vrrtf %-A•+� �aI PKI - <br />L <br />Address <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone Al yvr _ 3 go - <br />0 <br />tra <br />Conctor Name s At <br />Phone # 4f'/_ 7 8 -7070 ,r / <br />T <br />Contractor Address 3 t y2 Cit ,!j d.e.. CA Lic #,-�'70Q� .ClassC"2 <br />A <br />.� <br />Insurer Work Camp 2 _ a <br />TICC <br />a <br />Technician's Certification Number S 2/ _ Expiration Date <br />R <br />ICC Installer's Certification NLrnber 5-2..r.4/1910 -4 / Expiration Davie 8� <br />_ <br />O <br />Tank ID # Tank Size Chemicals Stored Date UST Instated <br />Currently/Previously <br />T <br />A <br />N <br />K <br />P <br />CApproved Bkmroved with conditions DDisapproved <br />L <br />A <br />YW(See Attachmentth Conditions) <br />N <br />Plan Reviewers Name ! C� Ltd`' Dam <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN ODUJ'rY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, OW(RONMENTAL HEALTH DEPAR7MENT, OWyNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOIMNG: <br />7 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CBBTIFIES THE FOLLOWMNG: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS tSSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER`$ <br />OF CALIFORNIA.' COMPENSATION LAWS <br />�J J <br />APPS Syrmure Dila - !1 <br />BILLING INFORM - N: <br />Indicate the responsible party to be billed for additional EHD Staff time expended beyond permit payment coverage per tank If <br />the party designated below Is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the bOuV by signature and date below. <br />Z <br />NAME /���� •�7 ¢�TITLE C�a. �`IH� PHONEaX S-/ - %ig8- %�fJ�e/pZ <br />EH230038 (revised 17/31107) <br />