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Oct 01. 02 09:51a Elite Ia Contractors Inc 2094616342 P.3 <br />ENVIRONMENTAL 211"EALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton., California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPUCATiON FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />i II... RRTRAFIT •I YIPIPINC RFPMRIRPTRAFIT F ftJDC REPAIRIRETROFIT []COLDSTARTfEVR UPGRADE <br />F <br />EPA Site # Project Contact & Telephone # - - �- ( 9 <br />A <br />C <br />Facility Nam CCvYY ,t_ ' r f C �f YI n t PhORe # , 3.1_ -. L• t , -2_ <br />AddressF��� <br />7 <br />Cross Street <br />Y <br />Owner/Operator Q f) 1 . r' t rO 1 ` j Phone # �`i J �C �t���•. <br />o <br />Contractor Name <br />Contractor Address ' 5` °) V �' t �C' c f 1 CA Uc # Class A ( (� <br />A <br />Insurer C ° , Work Comp # <br />T <br />T <br />ICC Technician's Certification Number Expiration Date <br />R <br />ICC Installer's Certification Number Expiration Date <br />Chemicals Stored <br />Tank t0 # Tank Size CurrendylPreviously Date UST Installed <br />T <br />A <br />N <br />K <br />P <br />DApproved DApprved with conditions ❑Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNT/ ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY. ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I 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" CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." k <br />Applicants Signature '1 i �,' 1 t� ' Title_ <br />t31LLINU INFUKMAI IL)N: <br />Indicate the responsible party to be billed for additional EHD 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 .il i - r i I�.0 ' 1%(�l�')i.1 TITLE �i'.�itt `:�t� �1�AC PHONE It <br />ADDRess 2 > .-- <br />54GNA7l3RE <br />EH230038 (revised 12131!07) <br />1 <br />