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Oct 29 14 09: 03a ElitIV Contactors 12094j.,342 3 <br /> P- <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> - SAN JOAQUIN COUNTII' r ; <br /> 600 East Main Street, Stockton, California!),' 202 9 2014 <br /> Telephone: (209)468-3420 Fax: (209)463. 143ILNVIRONMENTAL HEALTH. <br /> APPLICATION FOR UNDERGROUND STORAC = TANK DEPARTMENT <br /> RETROFIT OR PIPING REPAIR PER r11T <br /> THIS PERMIT EXPIRES 750 DAYS FROM THE APPROVAL DATE, INDICATE PEfM TYPE BELOW: <br /> O TANK RETROFIT D PIPING REPAIR/RETROFIT O UDC REPAIR/RETROFIT C -'OLD STARTIEVR UPGRADE <br /> F EPA Site# <br /> A . Project Contact&-Telephone <br /> C Fac! Name I <br /> �`� Fill- <br /> � Address- 'I I �� 1. ne# ' C <br /> T .Cross Street 95W, - <br /> Y OwnWOperator <br /> o Contractor Name - Ph 1e <br /> N Fh 1e <br /> T ContractorAdtlress �'- 1 CALX# :�_"! - <br /> A Insurer - - Class <br /> C s Vic I Comp# <br /> T ICC Technician's Name <br /> o <br /> Exl anon Date . <br /> R ICC Installer's Name - <br /> ExF •ation Date <br /> Tank system work area Tank Size - Date UST <br /> n.o.STWPhvs=13.911lukdaled,,000irzeh.J Chemicals -Currently <br /> Installed <br /> T <br /> A _ <br /> N . <br /> K _ <br /> --- PApproved <br /> L.. _.... _._ . _ pproved with Conditions Q Disapproved <br /> A - - '(See A chmentWith Conditions) <br /> N Plan Reviewers Name <br /> Date <br /> PAQUI M MUST PERFORM ALL WORK N ACCO WITH SAN JOAQUIN COON ORDINANCES,STATE L,,V;,AND RULES AND REGULATIONS OF SAN <br /> THE PERFORMANCE <br /> ENVIRONMENTAL THE WORK F HEgL1N DFPARTMEN7 OWNER OR LICENSED'AS SIGNATURE CER r5 iS THE FOLLOWING; 'I CERTIFY THAT M <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITIS ISSUED,I SHALL NOT EMPLOY ANY PERSON E ra '.H A MANNER AS IN BECOME CERTIFY <br /> THAT <br /> TTIN <br /> HAT IN THE PERFORMENSANCIONE <br /> OF THE CALIFORNIA.' H 1111 CTOR'S HIRING OR$USCONTRACIIHG SIGNATLR. CERTIFIES THE FOLLOWING: •I CERTIFY <br /> HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I$HALL EMPLOY PERSONS SUS 3CT TO WORKERS COMPENSATION.LAWS <br /> OF CALIFORNIA." "' <br /> PPllParx'a Slgnalure - 1 � _ .. j ... . <br /> Tne Dat l_ <br /> - BILLING INFORMATION: <br /> Indicate-the responsible-party-to-be billed-for additional EHD staff time expended beyond <br /> the party. designated'.below Is-different thanthe <br /> permit Parti t- ayrnent coverage per tank. If <br /> responsibility for the,billing by signature and date belowrmit applicant, e.g. property owner,- the arty must acknowledge this <br /> E_I_lK ff� 5P-*j�-w jPH)I <br /> ADDRESS �Y�r7 <br /> SIGNATME_ t Y114r' <br /> E4230038(revised 0811/11) <br />