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Sep 26 11 10: 20a Elite IV Contactors 12094616342 p. 1 <br /> l I � <br /> ENVIRONMENTAL HEALTH DEPAR'"MENT <br /> SAN JOAQCIIN COUNTY <br /> 600 bast Main Street,Stockton,Californim 95202 <br /> Telephone:(209)468-3420 Fax: (209) 468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TAP <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES hell DAYS FROM THE APPROVAL DATE INDICATE PERMrT TYPE:B :JW. <br /> O TANK RETROFIT O PIPING REPAIRIRETROFIT O UDC REPAIRIRETROFIT O COLA►I r ARTIEVR UPGRADE <br /> F EPA Site A Project Contact b Telephone X <br /> A — <br /> C Facility Name Phony A <br /> Address Y <br /> L <br /> Cross Street <br /> T _ <br /> Y Ownerl'Operator FPhorw <br /> e tl <br /> r L <br /> C Contractor Name -�{ -Y i tX`� �� - -- 11 <br /> N Contractor Address 3,r ( �;(t r y ( CA Lick (',(` _' Class A Z <br /> R <br /> Insurer f ` Work I;t r p 1i <br /> T ICC Technitaa 's Name �(�� y Expiratil I Date j <br /> R <br /> �l <br /> IGC Installer's Name ' f Expiralit I Date <br /> cam. �;Ct.•�� -- -- - HCl '76N <br /> Tank system wont area Tank Size Chemicals Storedf;. - ntly Date UST <br /> It-67 p6ty—P,BI Rork debclw,UDC Irl.W.I Installed <br /> T <br /> A <br /> N — - <br /> K <br /> L. <br /> P Approved I J Approved with conditions -.I Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPt!CANT MUST PERFORM ALL MURK IN ACCORDANCE WITH SAN JOAQUIN COLINTY ORDINANCE*.STATE LAW;:,/ q)RULES AND REGULATIONS OF SAN <br /> JOAOUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTW'-S 'I I('FOLLOWING' '1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHIM THIS PERMrr IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SiIC +MANNER AS TO FWCOME SUBJECT <br /> TO WORKERS COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE C rITINES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR%HIGH THIS VERMrr IS ISSLAEO,I SHALL EMPLOY PERSONS SUBJil C 1 O WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicant s Signature _ Tltter� pate a , <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit: p I ment coverage per <br /> tank. If the party designated below is oifrerent than the permit applicant, e.g- property owner, the pa y must acknowledge <br /> INs responsibility for 1he billing by signature and date below. <br /> NAME TI't LE PHONI: <br /> ADDRESS <br /> SIGNATURE OATE <br /> E11230038(revisso 07r22110) <br /> 2 <br /> 2011-09-26 12:14 12094616342 Paqe 1 <br />