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Jan IO 11 02:2Ip Elite 1V Contactors 12054616342 p_2 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> sou Fast Mam Sheet;Stocktmo,Cali[orlium 95202 <br /> Telephone (209)468.3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PEFMIT <br /> THISPE ZWr EXPUMS TBD wYS FROM TTEAPPROVAL ATE-w01CATE PERMITTYPE BELOW <br /> 0 TANK RETROFIT 0 PIPING REPAIRlRETROFff O LOC REPAIRIREfROFIT O COLD STARTIEVR UPGRADE <br /> F EPA Site i Tetepfane# <br /> C QK <br /> FaciW Name Phorp# -!F <br /> L <br /> Address _ - trio <br /> T Avc- <br /> Cross Street <br /> Y owrwrfoperaw Phdrle if c7�� <br /> 0 <br /> c Cmmaaclor Name y Phoned <br /> /`^ <br /> N Cortra�hr Address 'f CA UC# W7 Gass _ <br /> T <br /> 1 JIMA <br /> A Ycrrer VTfdrk Compit -Q <br /> T ICC TeCWdansName - ��D <br /> O ICC ktsiade's Name EVirubm Date <br /> R <br /> Tank system work area Tank Sae C he"d els Stored Currently Date LU T <br /> BA,p TNgAgI M lr adrrar,uoC h¢�J Installed <br /> i <br /> T <br /> A <br /> N <br /> K <br /> P C Appy El Approved with Conditions L Dea <br /> L (See Attachment 1Mth ConditfOns) <br /> A <br /> N Ptan ReWewaa Nam Date <br /> APPLICANT MUST PERFORM ALLWORK IN ACCORDANCE YMII SAN JOAOUIN COUNTY OMAN LACES•STATE LAWS,AND RULES AND REGULATIONS OF S N <br /> JDAQUAN COUNTY,ENVIRONMENTAL HEALTH DEPARTNIENT-OWNHt rB UCFNS®AGENTS SIGNATURE CER nFIES THE FOLLD N6' 9GO"YTHAT IN <br /> THE PH+FOR/MNCEOF INE woex,FORNMCH THIS PERMR IS-ISSNED.I SHALL NOT Eldl Y ANY PBtSON IN SUCH A-WNNER AS TO fECOW SUSIECT <br /> TO WORI@R"CDAP34sAT1ON L AVS OF CAUFORNIA• CONTRACTORS MIRING OR SUBCONTRACTING sIGW WRE B;rnFum THE FOCLo1MNG: -I CERTFY <br /> -TINT IN THE or Tic NARK FOR VANCHTMs PERNHT 6 Mssum,I S ALL EMPLOY PERSONS SUBJECT TO wOM/:MS COMPENSATION LAWS <br /> OF CJILFORNIA' <br /> J i <br /> AFP W-Sip — —akLe 1Tt U v z�jOab <br /> BILLING IN MATION: <br /> InTidste tie responsible party ID be bided for addffimhal E}10 staff time expended beyond per"Payment Coverage per <br /> farhk IF the part'des4naled below is diferent Blau Ow permi appima t,e.g.property owner,the party must adowledge <br /> this responsbU fD The biRng by signature and date below. r� <br /> NAI T L:'ot l J it of P,IDNEi <br /> ADDRESS <br /> qt G i yL 1 b - -! f i o fi [t. <br /> SIGNATURE <br /> EH230WB Qedaed 07 TD <br /> a <br /> Z d 99MOL999 6uue8w6u3 A0AO0 d L L:t 0 LL OL UW <br />