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Work'Order: 2255439 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 601)Fast Main Street,Stockton,iCaliforn ia 9i2O2 <br /> '117clephone:(209)468-3420 Fax:(21)9)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR <br /> THIS 1,041AIT I.XFIIFtES 90 DAYS FROM THE APPROVA.-DATE. 114()r-ATE PrRmIr TYPE BE-D-W: <br /> I <br /> TA-1WR=ETRCiFIT .1PIPINoR6PA1k-RETRO-lT JUDO RCPA-FIRLI ROF <br /> 1- EPA Site 9 Project Contact&Telephone# <br /> A <br /> Facility Name 1;rlp Z./3-, Phone# <br /> I L i Address <br /> Cross Street <br /> ()w ED'() rator Phone# <br /> Corivaclor Name Phone <br /> Contractor Address e CA Llc,# C la*ks <br /> Ins <br /> ICC Technician's Certification Wi riber _qr Expira tic n Date <br /> ICC Instaer's Certification Mum Expiration Date <br /> Tank LD 4 Tank Size Chemicals Sicred Date U'. <br /> Curren tly!Previou 51 y <br /> N <br /> K <br /> J.. <br /> Approved :i','(APPmved with conditions 'D:sapproved <br /> L ;See Attachment With Corlditi 0 r1s) <br /> Plan Revi Fwers Name_ Date_. <br /> MVST PEIRPORM ALL WORK INA CORDANCP W71-1 SAN OAQU14 CC'JN'Y ORDINANCES.STATE LAWS.AND RULES AN RE:.' <br /> C'U-IN k;0UNTY.ENVIRONMCNTAL HeALTt.DEPARTMENT OWNER OR LICENSED AGENT'S SIGNATURC.C--RTIF-ES THE=CUCIATNG <br /> -!IC PIEWORMANCE OF THE WOR<FORWHIC H THIS PERMIT is IsgiECI.:SHALL NOT EMPLOY ANY>ERSON IN SUCH A WAIVNER AS TO BE <br /> vv.)RCEWS COMPENSA!;ON LXAS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRAcriNc SIGNATURE CERTIFIES--HE <br /> =R*3 <br /> -IAT IN THL'PEAFORMANCE OF THE WORK I OR%NHICH THIS PERMI.19 ISSUED.i SHALL EMPLOY PERSONS NV13JEC, <br /> Jr C'.ALVORN•A." <br /> Ppl":.13ril 9 sq naUm T... <br /> BILLING W-RMATION: <br /> Indicate the responsible party to be bit I ad for additional El-LD staff time expended beyond permit payment coverage OL, <br /> the party designated below is different than the permit applicant. e.g. property owner, the party mus' acKnovol- <br /> ,espor5ib--ity tqr the bi4ing by signotwe and date below <br /> NA NI E TITLE PHONE d_ <br /> iIX REM- <br /> fi I rMATU R E__ <br /> EH239036(favified 873:07) <br /> Tanknology Inc. 8501 N.MoPac Expressway,Suite 400,Austin,Texas 78759 <br />