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Aug 05 13 10. 53a Elite IV Contactors 12094GIG342 P. 1 <br /> pn r f.►� 'y. y a r a .yt{ r�14v `:4Yy;y ►' r. .y.r>.�i.!' <br /> 3 <br /> . RECD . <br /> ENVIRONMENTAL H tALTH D E."PARTUFm ANUIN COUNTY <br /> SAN JOAQUIN ENV�F+ <br /> HEALTH DEPARTMENT GOU <br /> :NTI< <br /> 600.East.Main!.Street, Stockton;-California 9: 20 <br /> Telephone: (209)458-3420 rix �209j 403 '433 <br /> 1 r - <br /> APPLICATION FORUNDERGRC(UND STOM4C. TANK <br /> RETROFIT-OR'PIPING REPAIR PER HT <br /> THIS PERMIT EXPIRES 186 DAYS FROM THE APPROVAL DATE. INDICATE PEP M TYPE BELOW: <br /> D TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT C :OLD-START/EVR UPGRADE „ <br /> F EPA Slte# Project Contacf 8_TeleRhQnp_#- l9 <br /> C Facility Name Qn <br /> f h e <br /> Address <br /> T CrosStr <br /> s pet <br /> c� 2 <br /> Y Owner/Operator P le <br /> O u Contractor Name' <br /> P.Ic e# <br /> N ContractorAddress <br /> — <br /> R CA Llc# Class <br /> A Insurer <br /> C Rim Wx Comp#it <br /> T ICC Technician's Name <br /> o E:-pi .Aion Date <br /> R ICC Installer's Name <br /> E;pi dion Date <br /> Tank system work area _ <br /> (Le-57 piping sump,91 leakdatecW(,LAD 1n,etc.) Tank Size Chemicals Stor.t ',urrently Date UST <br /> Installed <br /> T 3 - <br /> A _ m <br /> N <br /> K _ <br /> P El-Approved ❑ Approved with Conditions — ElDisapproved <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name <br /> Date <br /> — <br /> 'AL. <br /> PERFORM ALL'.WORK IN ACCORDANCE WITH SAN JOAQUIN'COURTY ORDINANCES,STATE LAMS, 'AD RULES AND REGULATIONS OP SAN' <br /> OAQu'N.c0UNTY, E'NVIRONMENTAL'HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS SIGNATURE CERTr=rE THE FOLLOWING: 9 CERTIFY THAT IN <br /> I'IE PERFORMANCE A TFt 1NORK FOR WHICH THIS PERMIT IS ISSUED 1 SHALL NOT EMPLOY ANY PEI�SON.IN MANNER.AS.70 BECOME'.SllBJEC7IO <br /> 'NORRERS�OAiPEN5ATl [AOVS t5 CACiFUANIA CONTRACTORS HIRING 0R SUBCONTRACTING SIGNATOR-:c :f4AL4 S THE FOI.LOWINESU CERTIFY <br /> AT,IN THE PERFORM Op TFIE WORK FOR WHICH THIS PERMIt 15 ISSUE,I SHALL EMPLOY PERSON,$spp,Er rp OB!(ER S COMPENSA7aDN_LAW$, .,,..... <br /> OF'CALIFORNIA•,,,.- — : . -- <br /> pPBcant's <br /> r <br /> _.._:_.:..--..__.___..._.. . _. BILLIN.GJNFQRMATION: . . <br /> Indicate the responsible party to be bffled for additional EHD staff time expended beyond permit.X a; vent coverage per tank. If <br /> the party designated below Is different than the permit applicant, e.g. property owner, the Ila y must acknowledge this <br /> responsibility for the billing by signature and datA rtralrn v_ <br /> ��yy--t� <br /> NAME' (moi ~Pf!O 1 SSS 0 - <br /> _. .._..... ..ADDRESS..-. <br /> SIGNATURE ATE-.j. <br /> EH230038(revised 11li 1) #i <br />