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Oot Z9 14 03: 04p Elite IV Contactors 12094616342 p. 2 <br /> ENVIRONMENTAL HEALTH DE- :1ARTMENT <br /> SAN JOAQUIN COUNTY � E�..r �VED <br /> 1868 E. Hazelton Ave., Stockton, Callfomlcl 52 <br /> Telephone: (209) 468-3420 Fax: (209) 46E -3433 <br /> APPLICATION FOR UNDERGROUND STORA '4E TANK OCT 2 9 2014 <br /> RETROFIT OR PIPING REPAIR PE I MgNVIRONNIENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PI-F .IIT TYPE BELot)EpARTMENT <br /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIR/RETROFIT l COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> C Facility Name ' <br /> 1l: f lone# <br /> � Address Lou r.. H u <br /> I Cross Street <br /> T _ <br /> Y Owner/Operator I G I ',one# <br /> c Contractor Name C , ( . I E one# _ <br /> o _ <br /> N Contractor Address <br /> T • -65 6 411 CA Lie# i, `7007 ass <br /> A Insurer { % orkComp# � ^' ��' <br /> U f n am <br /> ICC Technician's Name <br /> T E cpimGon Date <br /> DICC Installer's Name <br /> R E (piradon Data <br /> Tank system work area Tank Size Chemicals:3l red Current) Date UST <br /> (I.e.87 piping sunp,91 look derectpr,UDC 112,e1cJ y Installed <br /> T <br /> A <br /> N _ <br /> K -- <br /> P ❑ Approved pproved with conditions — Disapproved <br /> L <br /> A ee Attachment With Conditions) <br /> N Plan Reviewers Nam Date_._ ////��Y/ <br /> APPLICANT MUST PERFORM ALL RC IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STA"E AWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONM AL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE :1 TTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON I SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKERS COMPENSATIO WS OF CALIFORNIA." CONIRAQTOR'S HIRING OR SUBCONTRACTING SIGtIA URE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORM CE QF TSH <br /> HE WORK FOR WHICH THIS ITIS ISSUED, HALL EMPLOY PERSOM1S OBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." )f <br /> APplicanrs Signature i /TIr1e a /,(`r'. <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond pe nit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, he party must acknowledge this <br /> responsibility for the billing ryby signature and date below. <br /> NAME��I.rYI�. , rUll.C.� TITLE , CIf 1VICLII •i _ HONE# <br /> ADDRESS Citi'✓} <br /> SIGNATURE 1.4 44 1 " _ TATE C,4;901 <br /> EH230038(revised 07-17.2014) <br /> 2 <br />