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rc» ib—>.yyb esea P.02/02 <br /> 01/15/2008 TUB 14:51 PAX 20946834A3 Sic BBD 2003/008 <br /> w <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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 /> I� <br /> This PERMIT EXPIRES 190 DAYS FROM THE APPROVAL DATE INDICATE PEFBIITTYPE BELOW: <br /> OTANK RETROFIT YJPIPINC REPNRIRETRDFIT nl1DC REPAaNiEtROF1T JCOLO START/EVR UPGRADE <br /> F EPA Site# Pro]ed Contact 6 Telophene 0 4,i{Ti a k irtc --1 g2S'-14Z-4ob0 <br /> A <br /> C Faedhy Name Che-j:o n y4m4T o n Phone# <br /> I1. Address 3400 Mac ra C C/1_ 953'7L <br /> I <br /> T Class Street X- 7-0!C7-0!C <br /> Y Ownsn'Operstor rays S I n r, <br /> o ContraclarName ieal i Qe+0ol-eaii Phone 92S`Qp2, -YOIo0 <br /> T Contractor Agdreas 171P IAf Mln oStplea&Cy)4-en CALic# tw1gl} Class ND <br /> RA Insurer ryl1 Can-1-7AC 'TylSkt2lt'l[✓ JWorkci A O'S36IS-9 <br /> DICC Tedtnlcian's Cerbftcallon Number aOS(p 1- <br /> T UT Expirafion Data <br /> O <br /> R ICC Installers Cenlflcation Number 1 Expkation Date I Z)1 6{/D g <br /> Tank 10 0 Tank Size Chemicals Stored Dale UST Installed <br /> Currently/Previously <br /> T q <br /> A <br /> N <br /> K <br /> P []App Appi with conditions 00eapproved <br /> L (SAttachment With Conditions) <br /> N Plan Reviewers Name �V DSM <br /> APPLICANT MUST PERFORM ALL WORx IN ACCORDANCE Wi SAN JOAQUINNTY ORDINANCES,STATE LAWS,AND RULES AND REGUlAT10NS OF SAN <br /> JOAOWN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LIC 880 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT iN <br /> THE PERFORMANCE OF TME WORN POR WMICN TMIS PERMIT 1513511 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 •1 CERTIFY <br /> THAT IN THE PERFORMANCE OOF�THhEE WORK FOR WHICH <br /> ORKFORWHICHH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TD WORKER'S COMPENSATION LAWS <br /> CALI <br /> OF FORF{I�;/µ^'^^^"" ' AfV/iX!'lltf.(-�1 C� 0i /aa lob <br /> APOIeasls 5.91MIM Title ab <br /> BILLING INFORMATION: <br /> Indicate the responalble party to be billed for additional END staff time expended beyond permit payment coverage per lank. I <br /> me party designated below Is dlfferF i than the permit applicant, e.g- property owner, the party must acknowledge this <br /> resporlaibiFly for the bluing by Signature and data below. ll <br /> NAME (e-r14(-AI TIl�) PHONE 0 4(o 2- —4 0 L,U <br /> �N?n 2nS <br /> ADDRESS_ I 1JJ, /]n-t t na P 1160 S a v�-1,D n CA- G 4,S( _ <br /> SIGNATURE -Q -`--QQ"-' "La� <br /> CH21003111(mvived 12/31107) <br /> 1 <br /> TOTAL P.02 <br />