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Nov 21 14 02:39p Elite Iv Contractors Inc 20946 142 p.5 <br />_ .NVIRC�]V�M�NTAL HEALTH DE'ff - T . <br />- AC, UiN COUNT V ® <br />600 East, Main Street, Stockton, California 95202 <br />Teiephane: (209) 468-3420 Fax: (209) 468-3433 N O V 21 2014 _ <br />APPLICATION FOR UNDERGROUND STORAGr;ET` K.ONMENTAL HEALTH <br />RETROFIT" OR'1PIPING• REPAIR-PEPiWIT <br />..------ ... DEPARTMENT <br />.._._. <br />THIS PER10tr EXPIRES.180 DAYS fTiOM THE APPROVAL DATG. INDITE PEFtRNY TYPE Bl=LOw: <br />Q TANK R I ROF1T'. 3 PIPING REPAMRFMOFri" ❑ UDC REPAIR/REMOF17 o COLD STARTIEVk UPGRADE <br />FFE:PA:Sf:tA Project Contact. & Telephono # t <br />d,, ` <br />_ <br />1 Phone # Xi Ca _ <br />I. . Gss oStreet <br />T <br />COwnerlOpGrator �' ( Phone <br />O -A <br />CCI lil31[i0r NalTle - I` I r' Phone # 4' + <br />RCDntzacWAddrm ' - .' it ?' i CA Uc# �! �j ^ `t Class <br />A Insuror Work Comp # C' �',� )t I ho") <br />T ICC Teehnleiail's Name Expiration Data <br />R JCC Installel's•Name- <br />Explratlon Date <br />TankWaroa Chemicals Stored Current! Date UST <br />tL4 trr n oaw moy Instalk?d <br />T <br />A <br />N <br />K . <br />P ❑ Approved Approved with condit ris <br />APAP <br />( ment WTI, CondlBons) ' <br />N Plan Revkwers Name — — <br />Date <br />ter.. _ .,- .,.<-....,^........ ......—.. ._... . _... . <br />L'CAW <br />aeU-rPMEMM ALL WORK IN ACCORDANW. WITH SAN JOAQUIN COUNTY OFIDMA STATE LAWS, AND RULES AND REGULATIONS CP SANJOAQU— <br />IN.CDUNTY. EWROMACNTAL HEALTH 09PARTMENT. OWFIER OR LICENSED AGEWM SIGNATURE CERMES YHE IfOLLOWINO -1 CCRTIFY THAT tN <br />E-PMVTW NCZ, W YHE WORK FOR WH" THIS PCRMIrIS ISSUED, I SHAD. NOTCMPLOYAWPERSON INSUCH A.MANNER AS TO BECOMiw WOJECT.TO <br />oRKEA'S'COWr_NSATION-LAft'oF MIF(SRfu 7 dONrMAt7f6R'S.HIRWG OR SUBCOknFi CT1NG..3KINATURE CERTIFIES THE FOLLOWING; '1 CERTIFY <br />THAT rN•T"C'PffWORMANCr OF-THr; WORK Poll WHICH"THISF'GRMIT IS.I :sUCO, I SHALL FItPLaY F�IiSCINS'SUBJeCr TO WOFiJfER i COMPENSATI(aN LAWS. <br />OF:CALIFORNIA?..,.._ . ,_.-...:...,,.._......, <br />1 r� r • <br />Appll(•siprg � u r ` � I .�',� i 11-� ,roi� f , v, r •. - ... ,ti ►.� + ... , f .. . , � _ `l 1 � 1 c:. <br />-OILLING INFORMAMN <br />_._. _.... , .indicate the cesponslble party_to•be4lllad-fQr additionaj.E staff-Ume expended :beyond p ermit payment coverage per tank. If, <br />_. <br />•. the.partjl_d631gr1et6d_below`Is'.dfffiontthari"the• rmit 1 <br />l app k ent, e 9 Property owner, the -party must- acknowledge Itis <br />rgppm bilit ry for the _ g try &Ignahrro and date t>e <br />NAME ������ 5_� . ► i i IC � � — . �' - •-- {� 1 ' ........T_ �—_ .1(,. _� : � - <br />ADDRESS': <br />SIGNATURE <br />DAT1G <br />BV30M (MOSO&0811/11) <br />2 <br />