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Jan 10 11 02:2Ip Elite IV Contactors 12094616342 p_2 <br /> r <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> WO EaaNISM Street,SIb)dd0Ttr CaMbr&M 95202 <br /> Telephone:(209)468.3420 Fa=: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THISPER10T EXPIRES ISO DAYS FKW TFEAAPROVK DATE-JNOIOATEPERMITTYPE BELOW <br /> 0 TANK RETROFff 6 Pilrikk9 REPAID MEMOM E CAC REPAIRJREPROFIT 0 C=STARTIEVR UPGRADE <br /> F i3HA Site P Projed Camlad&Telepluro$ =6L <br /> Facilly Nagle Phone DAX <br /> LAddress — <br /> T cross Sheet <br /> r Orrtrx/OpeT&oT phme$ <br /> c COTWb me <br /> Na "� Phpne tf <br /> N CoraTac9xAddJass 'C CA LRC 91 (307 Class <br /> T <br /> -r warlc cDmp s -0 <br /> T ICC Technician s Name Expiration Date <br /> RICC 6LsloBer's Narrle _ Expr�non Date <br /> Tank system work area Tank S¢e Chermcehorecurrently Std Ctly Date UST <br /> lk m NF7..c.w ra ar.v.unc 12aIy Installed <br /> T <br /> A <br /> N <br /> K <br /> P D Approved t*Pwo-ed with conations Li Dmapp wed <br /> L <br /> A (See A#Xhn erA Wdh Condon) <br /> � <br /> Plan Revierers Name - '- <br /> APPLK:ARr MUST PSWORN ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY DRDlNNCFS,STATE INNS,AND RULES AND REGULATIONS OF SN, <br /> JOAQUIN COUNTY,EWRONNENTAL FUALTH DEPARTNEVR.DINNER OR UCENS®AGENTS SKiUTuRE CERTIFIES THE PCL1DYN4G: 9 CERTFY THAT IN <br /> THE Fr RFORIMNCEOr THE NORK.FORV"CH TMS PEMV IS ISSUED.1 SHILL NOT I3111PANY PSLSON IN SUCH A WINNER AS TO 913GOME SUMECT" <br /> TO WOR1d:n5 COW"SATION LAWS OF CALIFORNIA' CONTRACTORS HIRM OR SUWANTRACTMG SN3NATURE CERTIFIES THE FORONNG. n CERTFY <br /> -THAT IN THE PERFOEIMAKE OF THE WORK FOR IYHCR TMS PERJIT IS FLIED,I M44L EMPLOY PERSONS SUBUECT TO LLORMER'S COMPENSATION LAWS <br /> OF(ALFORNUL' r <br /> Appi W.SW_ [ TIC U Oeb l <br /> BILGING IN NIATION: <br /> inTicuffi he responsible party to be tilled for addtiialal EHO stalF time expended beyond pernA payment coverage per <br /> lank tf the petty dem below is different Man the pelmd appli ont,{e.&p�roopertyy owner.the party must acknowledge _ <br /> this leSpatsihiRy far Che billing by sigriature and date below �L' I 'r 6'10 Lf G'7 Pi1oNEs �y� <br /> NAME Vnii tl l(!' .Q r _F 0,4 <br /> ADDRESS 9$5 ' u i yG --f� - -)b 1 r ;na ! ��. (V <br /> SIGNATURE DATE 1�L��f l <br /> L1/730cas(MWsed DT to 77 <br /> 2 <br /> 7'd ggZR9Ti/99R 6uu9aut6ua A9AO-) dLL'b0 LL M Uer <br />