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1�1I RCIfi T) �IFILTH: E PARTMENS' <br />S/� t AQU-iN- COU NTY` -REGEiVED <br />60p -:East -Marl Str*t;-Stockton, California 95202 - <br />T>Elepft -(209) 468,3433. <br />MAR 16 2015 -. <br />APPLIOA "ObtFOR UNDERGROUND STORAGE TANK <br />ENVIRONMENTAL <br />RMt <br />FIT REPAIR"P'ERMIT <br />PERiuEIF FJCPIRE$180 DAYS FTtOM THE APPROVAL DATE INDrCATE PERMIT TYPE BELOW: <br />QTANK:RETROFIT J]PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑COLD STARTOM UPGRADE <br />BILLING. INFORMATION:. <br />lndicafe-thexesponsibls-party-t-bs-bAled#sF--addidonat-EHD-staff time-e�cperldack beyond; permit "jt-pat] t]t er ge:,@er tianit.:._tf:.._: <br />.-RCfy igribelovl�isIfie%ems=ifia�i fhe Perariot-app]icant,-eg_ropert}' owner; the --part mcg acknowledge this resp6nsiO' <br />fore bilfinc by signature and date below..,., . <br />7 MIM <br />SIGNATURE 'C {�R'E <br />Eti210438 (reyised'0811/11 } . . <br />2 <br />Project ContRat. & Telephone # - to C <br />Phone r� <br />--AddreSS2 t6 on p] l L <br />i <br />T'' <br />Cross Street <br />Y. <br />OwnedOperator Vis; <br />C <br />Phone i 82 -� 1, <br />. <br />Phone # - <br />o <br />:Contractor �.`� <br />T <br />ContractorAddress2 . , CA Uc # ("),� 1 GlassAUL-10 <br />Work Comp # LkVq <br />A <br />T <br />T <br />ICC Technician's Name Expiration Date <br />R . <br />-ICC Installers -Name. - Expiration Date <br />Tank system work area Tann Size Chemicals Stored Cun-errtty Date UST <br />{I -e. a� pP�a tle�ctar. UDC err. era) installed <br />T <br />.A <br />_s <br />... ........ <br />P1.1[� <br />..—L <br />A <br />APiHQ. APproverl with Txmditions ❑ D' approved <br />-- --- ----• - ---- tftt�t <br />N <br />Plan Reviewers Name Date <br />PFUCANT MUST PERFOW Ati WORK-IN ACCORE)ANCElyW9TFi SAN''"QUIN COUNTY ORDINANCES, STATE LAM. AND PULES AND REGULA17ONS OF SAN <br />:- <br />JOAQutN;COUNTY; ENVIRONMENTAL'HEALTN'DEPARTMENr. OWNER OR LICENSED AGENTS SIGNATURE CF_RTI S THE FALLOWING:._'I CERTIFY THAT IN <br />THI=:TERFDtiMAAIC E_OF.THE WORK FOR WPJCR-MIS PHRMIT:IS ISSU®, I SHALT_ NOT EMPLOY ANY PER-SKM IN SUC i A MANNER 9ECOMEr SUBJEC <br />_TO .M. <br />INDRKEf S COMPENS TIOFfL44 OF CI�L� iJRNiA 1 ONTRACTOKSiIIRINC, OR B&iJ5d0 rfiFb CdbNG SEGNATURE CIERTIFTES-THE,FOL)-OWING- 't CERTIFY <br />— <br />•I'-gN.THiE.PERFORMANEE eF-TH_ r: WORK FOR IA+iijCf-k HM—PEiMiT IS ISSUEE)' I SHAT L F' #PLOYP,�Sgi�lS'SliB,iEECT' iT]''r{(SJi R'5 Ci3141PEL`1SA71(AII,LAW$ <br />BILLING. INFORMATION:. <br />lndicafe-thexesponsibls-party-t-bs-bAled#sF--addidonat-EHD-staff time-e�cperldack beyond; permit "jt-pat] t]t er ge:,@er tianit.:._tf:.._: <br />.-RCfy igribelovl�isIfie%ems=ifia�i fhe Perariot-app]icant,-eg_ropert}' owner; the --part mcg acknowledge this resp6nsiO' <br />fore bilfinc by signature and date below..,., . <br />7 MIM <br />SIGNATURE 'C {�R'E <br />Eti210438 (reyised'0811/11 } . . <br />2 <br />