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Jan 13 15 03:02p Eli* Iv Contractors Inc 209461634? <br />p.4 <br />HECEIVEC <br />JAN 13 2015 <br />EN1/lRON.fVIENT:AL HEALTH DEPARTMENT <br />�4N-JOAQUIN COUNTY <br />VI <br />NMEIVTA <br />- <br />600 -East Main Street, Stockton, Califoinia 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3.433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR -PIPING REPAIR PERMIT <br />- - - — TLBS PFRWISIFFES 180 DAYS M101 THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />o TANK.RIMORV o IRlR PIPING REPAMORT 0 LIOC REPAIRIRETROFIT ❑ COLD STARTIEVR L]p[tRnnF <br />A <br />Lbnha(x & TeleptlOnD <br />."I <br />G " <br />I <br />FaCl1ity NB,ne lj' I t Photic j (:i t <br />Address <br />1 <br />Crnss street <br />Y <br />Owner/Operator � <br />c <br />q <br />Contractor Name [f�T�. `j; <br />phone # ,� ' <br />T <br />Contractor Address'- • T'r' C]]t�iHY7i 1e,, ro crp� � C r7. i/S,`j. CA Lic �F C44('-kt Class A15( -k' IAV! , <br />R <br />A <br />Insurer • • ,.-' - \ <br />Pit^, •� n-.� ,$ 'f1 Work Comp <br />T <br />ICC Technician's Nam Expiration Date_ <br />R <br />R <br />JCC Installer's Name Explratlgn Date <br />Tank system Work arc,UDC Tank Size <br />9rdd�0v.s7+.vkdNector•uocl/{aa) <br />Chemicals Stored CUrrenl IY <br />Data UST <br />Installod <br />T <br />A <br />K <br />P.. d ApPuvd ppr—od with conditions ❑Disapproved <br />-L—•r_...__..__..— ---------...---... _ _.._.. faChmP.rIC1M h �ndi s). A / <br />N <br />Plan Reviewers Name Date (/ V <br />�Z?0 <br />STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />r'PUCANT MUST PERFORM AU,' WORK INA DANC W SA JOAQUIN COU O&sr.3NpAiURE <br />JOAQUIN.CCUNTY; ENVIRONN;ExrAL HEAL DCPAR OwNQi OR LIGENSEn GE CERTIFY -S THEFOLLOWING' 'I CERTIFY THAT IN <br />1ePr RFOrxMANCE.Or rn[WORKr'oR WrtIC6rTHIS PER IS ISSUEp, l SHALL NOr RSON IN,SUCH A MANNER.AS TO BECDNIC SUBJECT.TO <br />WORKER'S-L�OMPEFrc.,AT1OFJ-LAWS', OF CALYORNiA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTWIEs -THE FOLLOWING; •I CERTIFY <br />TIN THE PERFORMANCE OF THE WORK FQR WHICH -THMPHRMrr W ISSUED" I :BALL LMPLOY PERSONS'SUOKCT TO WORKER'S COMPENSATION LAW5 <br />OFCALIFORNIA;•''' „_ ... _. <br />pplk mfs skirlmUlq <br />___._.. _...._......... _..._....._ _._-_....91LL.INGINFORMATION: <br />_..__.—.- . <br />andtcale fheresponsible party, to be bined_for additional-EHD staff-time-e14iendetl-beyond Permit payment covemoe-per tank. If <br />-#lie_putY-dosignaled. below, Is differeni than.:the-.permit applkarIL a -g- Property Owner, the party must acknawledge this <br />responsibility fprthObilling try*gnpWM.and date below_ <br />.. `....,..a - --� � C,����----,RTe.E_iFi�'f% �zyf�'i3Zl`►(�.:..:,_,,,�ta_CJLti ei-ie'��)4l <br />ADDRk'SS ) y� <br />SIGNATURE:, <br />EH23003S (revived 01311111) j <br />