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Apr 05 07 09:07aElite Iv Contractors Inc 2094616342 p.1 <br />L1�" Jam <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUTN COUNTY <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 LIATE INDICATE PERMIT TYPE BELOW. <br />LIT ANK RETROFIT LPIPING REPAIR/RETROFIT --jirDC REPAIR/RE7ROFIT <br />F <br />EPA Site A <br />Pro' Contact & Telephone # <br />C <br />Facility Name�- <br />t <br />L <br />Address <br />I <br />Cross Street - <br />T <br />Y <br />Owner/Operator <br />Phone # <br />hw— - <br />oContractor <br />Name <br />/ <br />Phare <br />T <br />Contra Add <br />� CA "c # <br />Class <br />R <br />A <br />lrtsurer <br />Work Comp # <br />DI7 <br />C <br />T <br />ICC Te an's Certification Number <br />Expiration Date <br />O <br />R <br />_ <br />ICC Installer's Certification Number <br />y , - <br />'2lw � a�- <br />Expiration �� <br />Tank ID # <br />Tank Size <br />Chemicals Stored <br />Currently/Previously <br />Date UST installed <br />A <br />P <br />UApproved <br />KlApproved with conditions <br />UDisapproved <br />L <br />(See Attactanent Wdth Conditions) <br />A <br />rr,, <br />Plan Reviewers Name <br />APPLICANT MUST PEWORM ALL V.CRK IN ACCORDANCE WITH SAN JOAQLRN COUNTY ORDINANCES, STATE LAWNS, AND RLUDS AND REGMATIONS OF SAN <br />JOAa_xN CCL1NrY, EtvvtRoNMEJTAL HEALTH fjEFART ENT. OxMNFFt OR UCENSED ACB4T-S SIGNATURE CERTIFIES THE FCILOWIrc: -I ca;rnFY THAT IN <br />THE PERFORAAAJJC E OF THE E FOR VMICH T HIS PERMIT LS ISSt1ED, I SHALL PLOY ANY PERSCN IN S' I A MAt BiR AS TO BECOME bUE1JEGT TO <br />WtCRFCff25 COivtPENSA OF CALJFO RNIA" CONTRACTCIZS HRING OR RACTNNCi SIGNATURE CERTIFIES THE FOLLOWfNG: "I C87fiFY <br />THAT QV T} E P(�2FORM THE YK7RiO FOR WHIGfi THIS MfT IS rSS1®, I EMPLOY <br />PARSONS SLIB JECr TO ;/7WO7TK�t LAWS <br />OF CAL]FC�2t�IA' C//J AFiwarts Si� <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. if <br />the pa esignated below is different than the permit a can e.g. property owner, the party must acirnowiedge this <br />respo i i ty for the_ billin s" nature and date below. <br />NAM TITL AJ&NE IX `f <br />ADDRESS % <br />SIGNATURE <br />EH230038 (revised 818/06) <br />1 <br />