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S,ep 30,02 04:10p Elitev Contractors Inc 209461142 p.2 <br />ENVIRONMENTALL T <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 EXPPt1RES 190 DAYS FROM THE APPROVAL DATE. WDICATE PERMIT TYPE BELOW: <br />1 <br />I 1 ..w �K, ,�.r �Ro,wsre oe nwrorer roneir 1M pf <br />T I 0C <br />nlR/RKTQnF lr)LO STARTIEVR UPGRADE <br />F <br />EPA Site # Project Contact &Telephone # <br />� <br />Facility Name �,i✓��-1- (1 i f C � 'C1 n i Phone #/ <br />I <br />Address�2f' r:: a ra <br />T <br />Cross Street <br />Y <br />Owner/Operator Q i� C <br />Phone # <br />C <br />o <br />Contractor Name (�'' r '( n{'((�(' %`j / <br />Phone# <br />N <br />T <br />_ <br />Contractor Address ' ^ i• "r' ` CA tic # Gass — <br />1C' A C c ' !1 r! ) <br />R <br />Insurer ^ I Work Comp # ` `• `!1 <br />1. <br />G <br />T <br />ICC Technician's Certification Number Expiration Date <br />o <br />R <br />ICC Installer's Certification Number Expiration (Date <br />Tank ID # Tank Size Chemicals Stored Date UST Installed <br />Cutrentty1Previously <br />T <br />A <br />N <br />K <br />P <br />DApproved DApproved With conditions ElDisapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Dade <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY. ENVIRONMENTAL 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 BECOME SUBJECT TO <br />WORKERS COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA i <br />Applicants Signature n-) � ' Title_ <br />1:311-1-INU tNrUKMAI WN: <br />Indicate the responsible party to be billed for additional EHO staff time expended beyond permit payment coverage per tank. If <br />the party designated below, is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME y i,` �� JT &0--! i(k C-1 TITLE fv{',a ni( PHONE IR�A)C�� <br />ADDREss J J -2 % �. ° <,' -C' (y1 Of <br />SIGNATURE <br />EH230038 (revised 12/31M7) <br />1 <br />