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06/13/2008 11:45 2093651543 T WY PAGE 01/05 <br /> ENVIRONMENTALLT <br /> SAN JOAQUIN C . <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 P RMIT <br /> THIS PERMIT EXPIRES 00 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPEDw: <br /> BEL <br /> I.ITANK RETROFIT 01PIPM REPAIRIRETROPIT DUDC REP moPrT <br /> F EPA Site# Project Contact&T hone# <br /> C FacNlty Nares ! hox J u UOO''j,f P ions# S&I <br /> o"e. RAk, fl on CA 3 4a 6 <br /> T Cross Street <br /> Y I ownedoperstor .Phone# <br /> C <br /> oContractor Natne l 7-IJrW Phone# <br /> T Contractor Addrese ILLO U3. ! ftn 1-, j GA�Ic#^7f�/�® Class <br /> R Insurer qp IG` ( 'L O IL4 Work Comp# I qU to" 1 <br /> r <br /> ICC Technteian's CeAftation Number Expiration Date <br /> DIC InstaWs Certitioption Number Expiration Date <br /> F C_ <br /> Tank ID# Tank Size Chemicals Stored Date UST InstrI <br /> �led <br /> Cu raviously <br /> 4 <br /> A <br /> N <br /> K <br /> I <br /> P (•lApproved ElApproved with condition-. [.JDisapproved i <br /> A Nth(See Attachment VConditions)) I <br /> N Pian Reviewers Name Data <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUNN COUNTY ORDINA041111,STATE LAWS,AND RULES AND REOW1T10' OF SAN <br /> JOACUAN COUNTY. NTAL HEALTW 00OR LICENSED AGENTS TURF CERTOES THE F '7 CERT THAT IN <br /> THE PERFORMANCE OF THE FOR wmcpi TIOs PERMIT M issuiD,a siALL TOT EMPLOY ANY PERSON IN a"A AS TO t000Mr: CT TO <br /> wORKM COMPENSATION LAWS OF GIWPORNW CONTRACTORS HIRING OR BUSCONTRACTING SIGNATURE CERTIFIES Thi POLLCWING: i CERTIFY <br /> THAT IN TI eI pWWORMANCE OF THE WORK FOR WHK:H TINS PERMIT IS 0,i SHAtt EMPLOY PERSONS SUBJECT TO WORKWB COMPENSKIjION LAWS <br /> OF CALIFORNIA' <br /> s 516_M- TNIe C.P pole <br /> BIL—UN INFORhAA ON: <br /> Indicate the responsible party to ba billed for additional END staff ti rIe expanded beyond ponnh payment Coverage per tank `if <br /> the party designated below is di ferdrlt than the permit applicant, a g. r, the party must acknowledge 44 <br /> responsibility for the biilinq by signature and date below. <br /> NAME TITLE PHONE# <br /> ADDRESS - <br /> i <br /> SIGNATURE <br /> E14230088(revised 813/071 <br /> x <br /> I <br />