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12-09-'08 09:28 FROM-WENDT CONSTR. 1-209-547-9312 T-539 P02/08 U-653 <br /> ENVIRONMENTAL HEALTH rDEPARTMENT <br /> sAN joAQUIN COUNTY <br /> 600 East Mein Street,Stockton,California 95201 <br /> Telephone-, (209)468-3420 Fax; (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> ry <br /> THIS <br /> PERMIT EXPIRES lao DAYS FROM THE APPRL1vAL OATF_ tNOtGATE PERMIT TYPE BELOW: <br /> DtANK RETROFIT ❑PPING REPAIRIRETROPR ❑UDC REPAIRIRETROFIT ❑COLD START/EVR UPGRADE <br /> yq 31 <br /> 13 EPA site# CALO Z�D d i-1® Project Contact&Telephone#K+2trl <br /> C Fatality Name X-06,1 S"D OC.� Lt� t1l!f Phone P Z 333 10 3�S <br /> L <br /> Address IZZS U). LOG J <br /> I crass street <br /> Y pwnerAt3perettor Phone# J3°103 <br /> ® Cvntracta Name Qy+;�� Y S (%N VLC • Phone# 2h01.54 310 <br /> N ContrdctorAddreSs �d It{03 I (}I a �1 CA Lie#��? (� Class g C,t Me►F2 <br /> T work Comp O <br /> R insurd er i~y, <br /> A �} Expiration Date 3 ,t3- IC) <br /> c ICC Twfticiarvs Certification Number 6Z��1?,�5�7 T <br /> 7 <br /> R <br /> 911 <br /> ICC Installer's Certification Number 5ZS'J 1- Expiration Date ,0 <br /> Tank SI2a Chemicals Stored Date UST("tailed <br /> Tank ID# Currently/Previously <br /> T <br /> A <br /> N <br /> K <br /> P <br /> ®Approved Approved with c onditionS 116sepproved <br /> L (See Attachment With Conditions) <br /> NN �Dy2C-{ <br /> N Plast Reviewers Narne Date — <br /> APPLICANT MUST PERFORM ALL WORK IN ACCO CE WITH$AN JO UIN CQeJN9Y OrtniNANCES,STATS LAPS,AND RULES AND REGULATIONS OF TAN <br /> JOAAQUN COUNTY,ENVIROWENTAI.HEALTr1 DEPARTMENT.OWNER OR UCBNSEO AGENTS SIGNATURE CEEY"11PtE5 THE FOLLOWING: q CERTIFY THAT IN <br /> TtiE PAF E OP'n+E WORK FORvtMICli THIS PERMIT IS ISSUED,I SEtALI NOT EMPtAY ANY PE=RSON IN SurEa A MANNER A$TO BECOME SUBJECT To <br /> WORKERS CAMPSNSATION LAWS OF CALIFORNIA' CONTE�ACTOR S HIRING OR SU®OONTRAGTIN4'SIGNATURE GER1tiFll:S THE FCtLOWING: 'I CERTtFv <br /> THA dN?HE p�ItFORMANC THE WORK FOR WHIC-I ThlS PERMNT IS ISS 0.1 VALL EMPLOY PERSONS SUBJECT TC WORK�E/RS COMPE T10N LAWS <br /> OF CAaJFORNUI• Q 6r d <br /> Tie® Oat <br /> AOP ficenta SW4W, 13I1-1_ING t FORMATION: <br /> Indicate the responsible party to be billed for additional EHD Staff tune expanded beyond permit payment coverage per tank. If <br /> the party designated below is different than the PorMW aPPllcant, e.g• property owner, the Party must dcknrnMedge this <br /> responsibility for the boGng by Signature and date below. <br /> NAME v ®� 1 TITLt: PHONE A <br /> AODRE5S W <br /> SCt4ATU <br /> et4woo3g( 92139107) <br />