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SEP-08-2010 00:58 P.02i02 <br /> e <br /> ENVIRONMENTAL L <br /> SAN JOAQUIN COUNTY <br /> 600 East Main Street,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 190 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW: <br /> L�TANK RETROFIT Q PIPING REPAIPJRETROFIT [) UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact$Telephone# <br /> C Facility Name "7t0111, <br /> $i"3}lrl OA+ .w Phone <br /> Address 'f 1;� JZu .41"ri?- C LU$ 8 L • S!,1-b G li,:�1 G!Il / <br /> T Cross Street Q!✓ I'!'LOt.E M <br /> Y Owner/Operator n V ,. Phone# efacg-0 a-q Q(e-b <br /> a Contractor Name669 ltl.PLL,01A Phone to �'r�, V—qj,)L--04-9 QL, <br /> T Contractor Address I-7ig W yC mr , CA Lio# l C• Class _b I-�b 4� <br /> R Insurer M i I Worts Camp# A III u�blo isk <br /> C ICG Technician's Name M-4 OJ Expiration Date <br /> R ICC Installer's Name Expiratlon Cate t <br /> Tank system work area Tank Size Chemicals Stored Current) pate UST <br /> c..@ a7 o,lur ,U=la.w-) y Installed <br /> 7 <br /> A <br /> N <br /> K <br /> P Approved pproved with conditions r Disapproved <br /> Lea Attachment With Conditions) <br /> A <br /> N Pian Reviewers Name <br /> APPLICANT MUST PERFORM ALL IN ACCORDANCE WITH SAN JQAQUIN COUNTY ORDINANCES,STATE LAVA,AND RULES AND REGULATORS Of SAN <br /> JOAQUIN COUNTY,EN 0R ME AL HEALTH DEPARTMENT,OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 5MDM0 SUBJECT i <br /> TO WORKER'S'COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOVWNG: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR%"CH TMIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAW$ <br /> OF CALIFORNIA- p, <br /> ApplitawsSignIKO Tile Dale <br /> BILLING INFORMATION: <br /> Indicate the responsible party to pe biAed for additianal EHD atatf tirTle expends yo m rage per tank. If <br /> the party designated below is diferent than the permit applicant, e.g. property ower, the party frust acknowledge this <br /> responsibi/lity;for the billing by Signature and date felow. el �( <br /> NAME Lgrr- ( gayu TITLE '�O PHONE Al '"I 4&-2-q 1 E%�"C.ADOftESS Q d I A C1 CAS 34�b� G �7 .._, <br /> SIGNATURE 'l ! DATE <br /> EH230036(revised 0212WOO) <br /> 1 <br /> TOTAL P.02 <br />