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E1ElL=I:►LTH}EPARTiENT <br />- - w - -MY <br />AtGEIVED <br />BGO-East- Main Stre6t. Stockton, CalFfornla 85202 <br />Telepho6e..(209.) §B —34.20 Fax: _(209} 468-3433, LIAR 6 2015 <br />/tPPLICAxio,WFOR UNDERGROUND STORAGE TANK - <br />RETKG -IT WPIPiNG REPAIR PERMIT ENVIRONMENTAL <br />lard r�� �FapR?!6IIN� <br />- - " - - -- PHIS P3 RiAfC EXPklS 18fi LAYS TROM THE APPROVAL DATE [NDICAIE PERMIT FYPE SELOW; <br />Li TANK RETROFIT 0 PIPING'REPAIR/RETROFIT FIUDC REPAIRIRETROFIT p COLD STARTOM UPGRADE <br />F <br />I�BA $Mtg #, <br />Project Contact.&. Telephone # -)� <br />.:.Paulllty <br />Naiite ry ( <br />phone <br />l <br />L..... <br />Address _ <br /><( <br />I. <br />.. <br />Cross Street <br />.. <br />T <br />Y <br />(homer/Opwator <br />Phone# - ej• <br />0 ' <br />CatrtraclorName�, <br />N <br />T <br />CO&aC or•Address� <br />S% tt , CA. qct. CA ilc # 14t;? c Gass (� <br />R <br />A <br />Insurer.. = <br />, C ) <br />Wplic Comp # +� <br />_ <br />T <br />ICC Technician's Name <br />Expiration Date <br />•'R ..ICC <br />lnstalters-Name. _ .. _ <br />.. <br />Expiration Date <br />Tank system work area <br />Tank Size Chemicals Stored Currently Date LIST <br />Installed <br />OA 87 pipna =w, 91 WkdeWcftW IDC M er-) <br />T <br />.A . <br />N_ <br />P.- <br />❑ Approved <br />❑ Approved with Conditions EI .Disapproved <br />A <br />N <br />Plan Reviewers Name <br />Date <br />FYUC•ANT MUST'PERFORM ALL WORK-IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGIAATIONS'OF SAN <br />JOAQUIN,GOUNM-ENVIRONMENTAL'HEALTH <br />DEPARTMENT. OWNER OR LICENSED ADENI'S SIGNATURE CERTIFIES THE FOLLOWING: ,9 CERTIFY THAT IN <br />TFIE`PERFORMANQE,Of. 7.'ti♦R'� WORK'FOR WrilCFiif115-P..ERhiE%lSISSUED, l SFW,LL NOT EidPLOY ANYPERSON IN.SUCH g.MANNEt2.AS.TO $ECdMESUBJEGT_.TC! <br />4YgRKEfZS'COlal?EN�iTICSN-G41T4S��CSi; GAL��[7RNui' t�ONTRAC'rlk5 HIRING liR SUBC-Ohrfit4CTING SIGNATURE CFRRTIFIES-TRE FOLLOWING: 'I CER71FY <br />�T-IN-THE-PERFORhA,MICE EiF TNI= wORE( F©R iHHICI:f <br />THISPEFiMIT tS 455UF�: I SF{ALt_EMPL:g� P�.ft$OrIS SUB,(ECT T�61"(QRI'�k2'S GOd11PENSATiON.LA}N$ <br />yapG�s Signatwe '. <br />....---- -- - _ ---.. <br />.__—------ ---•---.-�1111NG. FNFQRMATIDhI:. _ <br />---ludlcaihponsd�de-party-td be 5rlled fol addanai Eli[}taf#irme expendect,beydrgf permit_payrrl�lt cgr+erage;per tactic <br />_. .. - - _. - . <br />n;;; <br />aff,e- scant, a -pro mnmer,..the- art most acknowledge this <br />permit aFP1 -9• p ItY p Y edg <br />ldy fpr the billing by signature and date f IqW.., - <br />�.:_PHONE t2L <br />SIGNATURE L l�'1 k DATE 3" . <br />EFIJK?38 {repiSed'0811/11) <br />