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Apr 04 02 12: 18p Elite Iv Contractors Inc 2094616342 p. 4 <br /> SAN JOAQUN COUNTY <br /> 304 East Weber Avenue,Third Floor,Stockton,California 95202 <br /> Telephone:(249)469-3410 Fax:(209) 3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> ¢f TMS PERMIT F)IRFS 90 DAYS FROM THE APr WAL DATE.INDICATE PERMrr TYPE.BELOW <br /> UTAH K RETRORT UPiPING REPAMtE MORT Lk=REPAIRmEmoFtT <br /> F EPA Site# Praject Cantact&TeleTiltnne# t`'I `�(r/»�+ <br /> A <br /> C Facility Name :'v Y1 r t f'V'rC� Phone 0- &1 Off:• "•�,j%i <br /> L Address i`'t`%q l s fl' Jt.'.• C c7 z.L,_ i' <br /> Cross Street <br /> Y Owner/Operator t1 :�t1 rv. k r Phone# <br /> con>r-ad>ar Name Phone# -;,� <br /> _ <br /> N contractor Adm z' " `` 1 <br /> T ' ,; t..A I.rC9 C`. •�bm <br /> A lttSrJrer �•'i.\leu' ZC'_5' ° vwb*Comp�.� - n <br /> C ICC Ted:nidan's Certification Plumber 5,2 qr `i s C Expiration Date •-' _�,. <br /> R ]CC kistallWs Certification Nuntw Expiration Date <br /> Tank lD Tank Size Chemicals Stated Date UST Installed <br /> T <br /> A <br /> k <br /> K <br /> P UApproved LIAPpmved wilo conditions Uoisapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name, Date <br /> Ofi=.-4LL.VJ--fM IKACCPQDANM VATHSANJq4QLW=Z9Y OFMW1rES,•ern? .ta4+;s.•,na .nWFW. �OFSAN <br /> JOACAAN OOLRJTY,ENV AL HEALTH DEPiARTMEiQT.CV44M OR LUNSED AGENT`S SKZ ATURE CERRE7FS T!E FOLWV 'I CERT(F'Y THAT W <br /> THE P 7RMNJCE OF 71-E WORK FORY"CH THIS PSMT IS I SHALL NOT 6fEWY ANY PERSON IN W04 A MWIER ASTO BECOME SIALIECr TO <br /> WORi(ERS CC UID- ATION LAWS OF CALIF dA.' CONTRACTOR'S HIRM OR SUBCONTRACTiNG SK WATURE CER i 4M 7HE FCLLOWM 'I COY <br /> THAT IN THE PERFORlAI1N(,.E OF THE WORK FOR VWi1O4 M-ItS PERMIT IS IMM,I SMALL EMPLOY PERSONS sLa EGT TC WOFGCE STM LAWS <br /> Dede <br /> 81WNG INFORMATION: <br /> Indicate the responsible party to be b'IHed for additional Edit)staff fie expended beyond permit payment coverage per tank_ If <br /> the party designated below is different than the permit appfiicar4 e.g. property owner, the party must aclatowsedge this <br /> responsibRy for the bilfmg by signature and date below_ <br /> NAME '4r' 6^ri L .L •••` a. � i,•L4 'nC7 Yi. fttl ✓ PHONE - c��f' �."✓')l <br /> ADDRESS !.s✓ =ri t '�s^" ~��C?C i � tt� I �' c 5 <br /> SIGNATLIRE� <br /> EH23DO38(revised 8MM) <br /> 1 <br />