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99/09/2009 WED 11:02 GAY 2094693433 BJC Elio — Stockton Sat:v 6Ea EQ Co <br /> ®003/0 DH <br /> ENVIRONMENTAL HEALTH DEPARTMENT APR 2 7 2010 . <br /> SAN JOAQUIN COUNTY SAN J j.,O0 ' i <br /> ENVY . NA:'r v7A NTY <br /> 600 Gast Mabi Street,Stockton,Catfl'ornia 9x"202 HEALTH D,-;,, <br /> TekphaDe:(209)46&3420 Fax: (209)468-3433 ^FITMENT <br /> APPLICATION! FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THMPEAi1700Rc3160DAYSMOM TME APPROVALCAM n"WATEPERMIT TYPEaELOW: <br /> Q TANK RETROFIT ❑ PIPING REPAIR1RETROFIT Q UDC REPAIMETROFIT ❑ COLD STARTiEVR UPGRADE <br /> Prosect contact 8 Talephono# <br /> F EPASile# Phone# � bto-gz <br /> A <br /> FacilYy Name <br /> I Address <br /> YI <br /> Cross Steel Phone <br /> Y Uvna Phan 1 z41— <br /> G 0ontract r Nama <br /> N Contractor Address r CA Lic# Q <br /> T work cDmp <br /> AInsurer <br /> C Expiration Date <br /> 7 IIx Tedtnican's Name <br /> R Expiration Date <br /> ICC Installer's Name <br /> pale UST <br /> Tank syslem workarea 'lank Size Chemicals Stared CorranOV inutaDed <br /> It.e,PM✓N,.na o,taut awM VDC,2 mcl <br /> A <br /> N <br /> K <br /> ❑ Approved Q Approved with cohdlnorls LJ Dlseppmvwl <br /> P (See Aitachment 1Mth Conditions) <br /> A Dal® <br /> N Plan Revlawws NaMQmm <br /> JOKIC TM UST PERMWALL <br /> EN7ORK INN TTIA E'DDRT�MENTOWNER OR LIEN8ED GENrSI��$IAiE CERTF"THE STATE LiOutl AND RFDp OWIN^Q 'ICFFRTIFYTHATIN <br /> �� <br /> THE PERFOFedo110E OF THIS PERMIT IS I6SIlED,I$HALL NOT EMPLOY ANY PERSON IN tiOf]i A MANNEii AS TO atL01E eLBiECT <br /> TO WORKERS COM NLAWSWO. FOR�n'hlpiMI3P C�eE TOWS <br /> SISSUFDOEHALLEN,PLt7YAER380NO6 aLsieOTTDTUIRE IFM WORKERS CAMPENSATgNtAVf9 <br /> THAT IN TKE PERF t <br /> OF CALIFORNIA' <br /> IYa <br /> BILLING IN DRMATION: <br /> Indkam the responsible pare'lobe billed for addillor W EHD staff time expended beyond permri payment a�arag acknowledge lank. If <br /> the party designated below Is different than IIIA pennH applicant, 0,0. property owner, the WY <br /> responsibility for the billing by slgnaWie"dale below. <br /> TITLEMMry�� <br /> NAME <br /> I <br /> ADDRESS <br /> I DArr`_ <br /> SIGNATURE <br /> erIx3C038 '."'0 z f <br /> J <br /> l d 99Z890L999 6uueeui6u3 AeAOO 269:90 0l 8Z AdV <br />