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08/05/2008 TUE 17: 13 FAX 0002/003 <br /> 07/02/2008 WED 15: 06 FAX 203433 SSC EHD • 12004/005 <br /> 07102/2008 WED 12: L3 FAX 0002/004 <br /> 07/02/2008 WED 11:57 FAX 20S 3433 SSC EHD ®902/004 <br /> i <br /> _._..- ..__......._...-_._.._..._......__.._.._...._._......_.............._...._.___.._......__..._....._.._...........__.___....._..................__.....,.._...................................._....... <br /> _............_.___......-_..._.___. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY CiZe.: sed <br /> 600 East Main Street,Stockton,California 9S202 --- <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 160 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> OTANKRETROFrr ONPING REPAMIRSTROFIT I.._(UOCREP'VPJRETROAT COLD$TART/SVR UPGRADE <br /> i F EPA Site# Project Contact&Telephone# <br /> A Fadlity Name IL''1 lrV'vr}.j{;jj`j( Phone#I'((., Ug - &4,, 10 <br /> L Address t{ , ` {ppb G6 <br /> I 1 I Cross Street <br /> T .70(0 <br /> I v lownedopeirator-1—ol �' (jry �L( Phone# <br /> CContractor Name g Gag / Phone# �( g70- g3 () <br /> 7 Contractor Addross - I°t 'gyp/ � _ I't aaaw�c CA Lie# - Class <br /> I A Insurer ldloCv' S_ Work Comp# LOA'7691)100-4,177 /7 <br /> G ICC Tecllniclan's CerttBcalion Number n Expiration Date 5,(",t TliL <br /> i r Ste ScLC31A t id't, r/tr-41JS!si: <br /> n ICC Installer's Certification Number il, l u Expiration Date vl <br /> PPIanReviewers <br /> ank ID it Tank Size Chemicals Stored Date UST Installed <br /> Currentty/Previously <br /> .... _7....... PApproved pproved Wiith conditions ODisapproved <br /> L (See Attachment With Conditions) <br /> A <br /> Nme <br /> APPUCT MUST PERFORM AI:C.WP(iK IN AGCQRQnN6E.WI,T,H_SAN.LQA0.UIN.EOUN7.Y.OROINAMCES,..S7ATE.LAWS,.ANO.RUCES.AND.REGULA730NSDF.SAN.._....._.__..... <br /> JOA'OUIANN COOMTV,ENUIR-ONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALT.NOT EMPLOYANY PERSON IN SUCH A MANNER AS TO BECOME SUSJECTTO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT W THE PERFORMANCE OF THE WOR FOR WHICH THIS PERMIT IS ISSUED,f SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OFCALIFORNIA." <br /> 7-2-P/�, <br /> Appatanra SlgnalWe T0I __ / / Dale <br /> ti BILLING INFORMATION; <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per lank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibilityforthe billi <br /> n <br /> g by signature and date below. 440/ <br /> ^ <br /> NAME fY��'�e. / fZCMGr+r')S TRLE /TIMI%".Y.•C/CLe�GL IS�rf'-�..PHI,ONrE�40 !17ID"�OA <br /> ADDRESS <br /> 1q.56�i f <br /> SIGNA111RE_4�Z� ,.- <br /> EH230038(revised 12131/07) <br /> _......_...._..._....__......_..._._...........................__._.._.._.._....: _ ,..._..-.. _.......__._...... .-'---_..._..-- . ... -...__..__... ;�.�� <br />