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May 15 2012 5: 59PM I LASE-R,7ET FAX 20 '46-8099 p.3 <br />U <br />831' 86/'2011 09:30 2694640138 ENVIRWMENTAi- HEA1..11-I PAGE 03/69 <br />ENVIRONMENTAL HEALTH DEPAWrMENT <br />SAN JOAQUIN COUNTY <br />600 Ea.9 Ntnin Strelbt, Stockton, California 95202 <br />Tclepbone: (209),168-3420 'Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFITOR PIPING REPAIR PERMIT <br />TNIe PBRMITIiWMER 110 DAYS PROM TI -10 APPROVAL DATE. IN0ICAT6rENMn-7YPJi illLAw, <br />o TANK RETROFIT 0 PIPING AEPAIRMETRORr 0 tIOC REPAIR RMOFIT 0 COLD SiTART1EW UPGRRA is <br />F <br />LPA FAA, 0�. � Project Conte at 6 Telephone # <br />G <br />Facility Name o �,>�-y� Phgne N <br />fav <br />Address 3� <br />D <br />Ci�>L�-.. <br />I <br />T <br />Crone Street <br />Y <br />Owner/Operator Phone 0 <br />'; I? -i <br />C" <br />0 <br />_ <br />Contractor Name ' �i/�f ( (,,p y\ Phone 0 <br />� <br />N <br />T <br />Ccnl�ctorAddrea -��� <br />� 1J J .? CA LIC # <br />GassIk d (D: ri <br />R <br />A <br />Jnsurar worxQOmpRo <br />'�. <br />Y <br />_ <br />JCC Techniclan's Nmltb Lvit Explrstlon Date <br />h <br />ICC Installers Name /j—� Expiration DalA <br />Tank uy+bm work areaTr,rlk <br />tl.eat opine wm'.9t+MM aar.r.000 In, •til <br />Size <br />J <br />Che rnlceb Stored Co Tently <br />Oate UST <br />fnstnllbd <br />7 <br />A <br />---- <br />K <br />P <br />F --J Approved �^ proved with oan(jillons LJ DlsOpprovad <br />lavae tWi01 r4won0) ) <br />Plan ROV14i"es Name cute 1 <br />APF LIGANT %WST PEJIPORM ALL WORK IN ACCOROANCE V147K SAN,1Gu+OVOJ OOUNTY ORD4N'ANCES, aTATI LAWa, ANC NVLU AND 11101GULATION1 OF FAN <br />JOAQUIN CD'JN Y, SNVIRONIVENTAL HEALTH DEPARTMENT, OWNEP. OR LICENSED AGENTJI SIGNATURE CFATJFIES THE I`O1.1AW11,14' 'J C;RTIFY THAT IN <br />'Mb PL'RFORMANCE OF TME WOAK FOR WHICh TH13 PERMIT IF IVA)ED, 13%IALt. NOT CNI+LOY ANY PFR90N rN eUC11 P MANN8P AS TO BECOME JUBJECT <br />TO WORKER'S COMPPNi;AT1aN LAINS aP UAUFORNA.' CONTPACTOVII HRING OR 3LBCONYRAaTING 44NATURG CIcRTIFies THO FOLLOWING; 11 cERTIPY <br />TI•AT IN YHH PERFORMANCE CF TRO WORK FOR WHICH THIS PFNMII•IS ISSUED. I SWLL WMM.OY PERSONS 61.10401 YO WORKERS COMPONSATtON LAWS <br />OF CALIFORNA• <br />'\rt <br />Indicate the rooponoWe party to bd billed for additional 6JHQ staff fitna expenddd beyond permit pl)yment eoveragm per <br />tank. If the parly dealgneted bdiow is differdnf than tho Parmlt applicant, e.g. property owner, the party rriui( acknawfedge <br />Ihls (00aonsiUlillt�(y,fol illja 011 bey Biijgn�Jalluuty and daft bf►luw. � } <br />NAME �dr LIb/31'! 1Lr-1►L—_ iNg I1'1•I: _.�v 1`L"�.71`..--- .�PMOONE 1: � ` 4�� <br />ADDRESS I)� ✓ � K R.Y'�_ � 1.1L.;•�C� l W ►�/V t (A <br />SIGNATVRE t,�a, 11, �n�1Y _ lY 'ti r° OATE__ <br />EHE31.)02LI((ewWvd 07123OIC) <br />