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ENU6 ZC��IVIENTAL HEALTH. �EPiARTIVFENT <br /> - --SAN JOAQUIN COUNTY <br /> 600 East Main Street, Stockton, California 95202 RECEIVED <br /> �® <br /> Telephone. (209)468-3420 Fax: (209)468-3433 <br /> - - - APPLICATION FOR UNDERGROUND STORAGE TANK JAN 8 0 2015 <br /> RETROFIT OR PIPING REP AIRPERMIT <br /> - ----- — <br /> PERMIT EXPIRES 180 GAYS FROM THEAPPROVAL DATE. BVDICATE PERMITTYPE BELOW: ENVIRONMENTAL <br /> TANK RETROFIT O.PIPING REPAIRMEIROFIT D UDCREPAIRIRETROFIT D COLD STARTWAfFNAWPARTAXNT <br /> ;F _�A. � . . _...... .. . PrDjw Contad.&Seleptrone <br /> ._ _C. Fadiity-Name : . . _ - Ptlnne _... - c - <br /> iAddress Q - <br /> L <br /> TCROSS;Streit - - - <br /> Y.. OwnedOperator - Phone - 5. <br /> o. Contractor Name "(' P�,i�mI,�ne <br /> T Contract-AddraBB �gp, CA Uc"tfijob- L Class e-116 .. <br /> -n Insurer Work Comp "Ab <br /> T ICC Technician's Name Exp'ra tion Date <br /> .. ..._. R .ICC Installer's Name . .. .:.. .. . ._-. . _._ - _Expiration Date <br /> Tank system MA area Tank Size - Chemicals Shred Currently Date UST <br /> B..mFaise wsc.sTlul;aslscmr.LOCIr{s1a) y Installed <br /> T . <br /> -A - <br /> P. '' ❑ Approved Appmved with conditions ❑.Disapproved <br /> -_.- '.____ _._--....._._.____-( AttachmentWith Conditions <br /> A N <br /> N Plan Reviewers Name Date ' �� J <br /> ___ <br /> ?PEIGANr MUST PERFORM ALL WORK IN ACCORDANCEWITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RtAES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY.ENVRi MENTAL HEALTH DEPARTMENT OWNER OR DCEN$ED AGENT'S SfGNATURE CERTIFIES THE FOLLOwMG 1 CERTIFY THAT IN <br /> EPFAFORMANGEOFTHEWQRKMRWHICHTMSPERMTTISISSUEDISHALLNOT EMPLOYANYP QN Ltf$VONA MANNERASTO BECOME SUBJECT TO <br /> ORKERS COlWENSATIOFI LAW$',DP OAQFORIJIA:- GTONFRA&bRBmRING ZJR SUBCONTRACTING SIGNATURE CERRFIES-THE FOLLOWING: T CERTIFY <br /> TIAATSNTHEDPERFORMANGEE OFTFIE WORKFpt WHIClt TTBSPERMfr IS ISSUED,i SHALL EMPLOY'PERSONS SUNECT TO WORKERS COMPENSATION LAWS.. <br /> . .. ---- ---- ---- ------`. ILI.ING IWORMATIoNC.... _. - . . <br /> -- Judicate-fheteSponsibleparty-tQbebdied-for-addiHeReIFID staff-time_expended beyondpermgpaykpeDt.gQyarage�per}r�nk,_.R ._ :... <br /> ..:." =' fie"-pally- f9rie�'beloM i d`rtferenl fl WAti�p'ehnit applicant,...eg_-propeAy dwneir Nte--party-must-:a&nowiledge-this <br /> ._respiI iTd _forthe bl91ng4y signature and:date below,._.. . ..... .-_--. ....:..._--. ..... _-___ _. _._... ._. .._ .. -. _.__ <br /> wuaE-�IS9�i�c,1}g�tri•int'�Pd�n—Tm� �iFPt2��;�"t1yC-_ PIroN�n L�k'� nl-fozr�`) <br /> nv_DRESS'z?5�5 itekd`Rriam,w,�7:�f(K'XtPv�E{�.9'S?� <br /> -SIGNATURE -DATE <br /> t323opsa(revbedeelT/N) .. . _ '.. - - <br /> 2 <br />