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Mar 17 08 05:52p P•1 <br /> RECEN`,.�', <br /> MAR 18 2008 <br /> ENVIRONMENTAL HEALTH DEPART MENT�OAQUINCOUNr,, <br /> LN✓IRONMENTAL <br /> SAN JOAQUIN COUNTY rIEALTi'OEPAATMEN-i <br /> 304 East Weber Avenue,Third Floor, 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 90 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW <br /> DADT ❑ <br /> NK RETROFIT ftEPAIR1RETFCRT DuDC REPAIRIRETROFIT <br /> F EPA Ste# Project Contact&Telephone ft � be*X k 1 &ry ha.(4 i-d9)bd ti-F33 <br /> C Facility Name p /Yjr n; A74-rt 7(p Phone# y 8 MI5-8S"b`Cp <br /> IAddress <br /> L ,9 s��� 5 . P�-+�ers�i-� Pa:Ss 9-d. <br /> TCross Street <br /> Y Owner,'Operatar N e',61-1 Pali elLPhone#�p 1).P.3'--r1`7 r7'7 <br /> Contractor Name <br /> o l p 'Y? r LC.; C . Phone# 09 $tISYgsy(F <br /> N Contractor Address! rOL FI 37D b <br /> 1 T CA Lie#I Class <br /> R Insurer r <br /> A C �n vv Worse Comp <br /> ' <br /> T ICC Technicians Certification Number <br /> T 52 SG`/s J.a Expiration <br /> R ICC Installers Certification Number <br /> 5 d-SP 51-/0 --u r- Expiration Date <br /> Tank ID# Tank Size Chemicals Stored Date UST Installed <br /> Currently/ <br /> T 00110h )q9z, <br /> Iq1Dtr4 <br /> }o�, iNK �b L90.5 �1 f1 l <br /> LDApproved DApproved with oond.tions []Disapproved <br /> A (See Attachment Wish Conditions) <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORT(IN ACCORDANCE WTH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND FEGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTYI DEPARTMENT.OVVNER OR LICENSED AGENTS SIGNATURE CERTIFIES rrE FOLLOWING I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR VVI-ITCH Ti4iS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO SECOME SUBJECT TO <br /> WORKEITS COMPENSATION LAWS OF CALIFORNIA:' CONTRACTOR'S HIRING CR SUBCONTRACTING SIONATLRE CERTIFIES THE FOU.OWNG: 'I CERnr-y <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSCNS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CAUFORNIA." <br /> Applicants Signature Title C o S1 <br /> a , Dale 3 )7 0 g <br /> BILLING INFORMATION: <br /> indicate the responsible party to be baled for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g_ property owner, the party mLst acknowledge this <br /> responsibility for <br /> �the billing by signature and date below. oft l' 10 2c4 el - jr12�7I or <br /> NAME! 1 Z, � rr�TITLE 1 <br /> ADDRESS f S L� GYM �i�Ct S S 0.[� f j A <br /> SIGNATURE <br /> EH230038(revised 018!06) <br /> 1 <br /> L'd 9BS8Sb860Z jJeyuJeg eJpueg d6L'90 80 i JeW <br />