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MAR-07-2008 03:44PM FROM- +9255517895 T-481 P.002/003 F-999 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,Stockton,California 95202 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES IAB DAYS PROM THE APPROVAL DATE.INDICATE PERMIT TYPE BELOW! <br /> I._ITANK RE772OFT AIPINe REPAIRIRETROFIT [11,10C REPAPURETROFY aOLD 67ARTIEVR UPOnAOE <br /> ..__._..l- �___. .. . .. ... .. . ._.._.._ _._._,.. _. _.._..._._........ .. . .. <br /> F EPA Slte# Project Contact 8 Telephone# <br /> � Faeility Name — Sosvl.cL .ra..A, Phone it -zo9kutal.7 Adores Opp IT <br /> Cross Street <br /> Y OWnar%Operator I E - Phne 4 -.D Contre'ctor Nem Phonefl 21 StD �'T`'-N CaIt7a4.TDr AdttreSS ,(�. \ CALK# C� Class \,Cr7-Rwz- <br /> T <br /> R tnaurer; ,d WOrx Comp fl \ Z.b3Gvlg-z>1 <br /> G ICCTetllniclen's Certification Number Expiration Date <br /> T <br /> R ICC In9tsllses Certification Number $ZSy l7 Expiration Date Z I7 p <br /> Talk ID# Tank Slue Ohemloels Stored Dale LIST Installed <br /> CurtenGylPrevicusly <br /> T 6l LN'+ Y+y d; V <br /> A <br /> N <br /> K <br /> i <br /> I <br /> P ! DApproved proved with Condit ions Doisapproved <br /> L A ment VAth Conditions) <br /> A <br /> N Plan Rovlewers Name <br /> I <br /> APPIICW MUST PERFORM ALLk IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,SATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN OOJNYY,ENV!ROW.ENTAL HEALTH ORPNRTMENT.OWNER OR IJCII AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CGRTIFY THAT IN <br /> THE PERFORMA,INCE OF THE WORK FOR WHICH THIS PERMIT IS ISSu EO,I SHALL NOT BAPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT70 <br /> WORKER'S COMPENSATION LAWS OF CAUFORNIA' CONTRACTORS HIRING OR 3UECONTRACTING SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY <br /> THAT W THE PERFOR NCE OFTHE WORK FOR WHICH THIS PERMIT 15 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S CCMPdN5ArION LAWS <br /> OFCAUFORrAAI• hx <br /> unM <br /> SII <br /> 1 1 111Io Dak <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be 1:41100 for eddlilonal EHO Stan 0me expended beyond permit payment coverage per tank. If <br /> Ne party oe5lgnated below is different than the permit applicant, E.g. property owner, the party must aGmowledge this <br /> responslbiityforthe birling\by Signature and d Ie-0CIOw. <br /> NAME , `p'•Aj��T`T�]+�G 'I'n'LE �t.a`1afe3'C.._'_ PHO�yNE^-t�FcL%-�c.7� I'- 1R 7 <br /> AMFIESS 1. <br /> SIGNI <br /> EFOOD38(W%4sr.01=1107) <br /> 1 <br /> II <br /> I <br /> I <br /> I <br />