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Aug 24 06 08:07a Elite Iv Contractors Inc 2094616342 P.1 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />304 East Weber Avenue, Third Floor, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fag: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />�-� <br />THIS PERMIT EXPIRES 90 DAYS �FFRROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />DTANK RETROFIT il� IPING REPAIR/RETROFIT 5Int: RFan <br />F <br />A <br />EPA Site # <br />- <br />Project Contact & Telephone # <br />C <br />Facility Name _ C -e ;,'7-4 YNi w ;- T <br />- <br />Phone # , 0 I 6 7- r 3 ci �9- <br />I <br />L <br />Address 0 1 J G rx U11 G� <br />I <br />T <br />Cross Street <br />_ <br />Y <br />Owner/Operator v✓v.- Phone #(2, ID ) 5' 913 i ; <br />oContractor <br />Name _ T % <br />Phone # <br />Nr <br />Contractor Address S 3 S r,l.� Lv u �z <br />CA Lic # G - U O )!� ClasSA <br />RInsurer <br />A <br />Work Comp # / 2 q- i & <br />C <br />T <br />ICC Technician's Certification Number -� ' � 0 _ V .T <br />Expiration Date 0 G _ <br />0 <br />R <br />ICC Installer's CertNlcation Number I <br />s2_6 93 80 t <br />Expiration Dat �%�-�z-� <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date (1ST Installed <br />T <br />✓ o�'o a� sal; <br />enc <br />j'�e GaS. <br />L;W <br />A <br />N <br />Ca U U L <br />(�r F- ')77 . A 5 <br />U IV i -C ry n W N <br />K <br />P <br />ElApproved AlApproved with conditions ❑Disapproved <br />L(See <br />A3N <br />Attachment With Conditions) <br />Plan Reviewers Name DateL <br />_ <br />APPL'CANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY; ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICFNSPA AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT !N' <br />THE PFRFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHA' L N v"'FI- ;PLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TG <br />WOR!*ER'S COMPENSATION LAWS OF CALIFORNIA- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br />THAT W THE PERFORMANCE,OF THE WORK FOR WHICH THIS PERMIT IS !SSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA' <br />Applicants Signature i Y I Tltles �i� {/ Date e% <br />BILLING INFORMATION./__. -- <br />Indicate the re nslble party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. Ir <br />file party designated below is different ihan the permit appitcant, e -g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME 7 TITLE_ 5 Q- e s M N9• PHONE 6 3 3 <br />ADDRESS2 S i �; � y w _�`n 1J S / c - <br />/-,_T- <br />SIGNATUREGfi <br />EH230038 (revised*&06) <br />1% •: <br />