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03/07/2011 10:27 2093651543 TANKNOLOGY PAGE 02/03 <br /> EwIRONMENTAL HEALTHDEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 In list!D i in Street, Stockton, CAifo rpo4j 95202 <br /> 1'ellephoae: (2919) 463-341296 Fax: (209) 468-3433 - Cif-i- ': <br /> APPLICATION FOR UNDERGROUND STORAGE TATs: RETROFIT OR PIPING REPAIR PERM17 <br /> u <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW; <br /> [] <br /> TANK RETRor-IT I-1 PIPING REPAIRIRETROFIT n UDC nPAIPMETROFI`6 COLD STAPTIEVR UPGRADC <br /> F FPA Site# Project Contact&Telephone# <br /> C F' cility Name 6-v,, 7_0 SL Lj� — Phone#ZCr1'Cf <br /> l _.,—...... ..,. _ <br /> �_ AG;1ft*$S_.3J:?�5� �*�c.+n+N^-art.. (,� ��,��••�G'�N G1A ,,,..��•1 .-�"' <br /> Y Griner/Open for Phone# <br /> O Cc•ntraCtor Mame 1fa&Aw0 L _ „ . _�._ - — - Phone# .....,, .�. .,. .. _— ... <br /> N Contractor Address LP I.e+�i CA Lic# X13 j Class <br /> A Ing{urer tmLctri,Cie -+ ��`�'�... Work Comp# ..— <br /> I IC,- Fechnician's Crpiration Mata <br /> o fC:; Installer'!;Name Expiration (,late <br /> Oate UST <br /> T-!r;K system work area Tank Size Chemicals Stored Currently Installed <br /> (Lh.. <br /> I'll{kpkul:xlMir.0'1 junk de Walor,UDC 1Q.Ula.) <br /> E< <br /> i <br /> P Approved pproved with conditions I Disapproved <br /> I. ( ee Attachment With Conditions) <br /> A <br /> N Pl,:n Roviewers Name Date— <br /> Ar'hr.ICnr.r MI�St'rel;"!F'OI�M ALL`OF�K IN ACCORDANC .WITH SAN JOAQUIN COUNTY ORDINANCES.37ATG LAWS,AND RUI GS AND RI.IGULA WN5 OF SAN <br /> ,IOAQIAN cowry,GNVIRONWNTAL I MAI.111 OLIPARTMENT.OWNER OR LICENSED AGENT'S SIGNA•LURE CERTIFIF.S TH• F•'OI.I.OWING: "I CERTIFY-HAT IN <br /> THE P'ERFORNIANCI"OF THL WORK FOF W[JICH THIS PF%RMI'r IS ISSUCO,I SHALT,NOT EMPLOY ANY?F.RSUN IN SUCH A MANNER AS'r0 faECOME SUE3JGC.'•I <br /> TO w(JIt1. rt";COMP FNSA'rI Or CALIFORNIA." CONTRACTOR'S HIRING or,SUBCONTRACTING SIGNATURL-'CFRTIFIE:S THEi FOLI.OWING: "I CFRTIFY <br /> rI rn r IN t�e pEFZF orarrtV.015-'O a wOtaK FOR �I THIS roE14MI1'IS ISSUED,I SHALL SMI>I..OY PERSONS%.III9JkCT TO WORK1-RTS COMPrNSATION LAWS <br /> OI•CAE <br /> f-LRPIicalln' SILEnatur <br /> BIL LING INFORMATION; <br /> Indioate the responsible party to be billed for additional F_HO Staff time expended beyond permit payment coverage per tank If <br /> the parry designated below is different than the permit applicant, e,g. property owner, the party must 2cknowledge this <br /> responclbility for the billing by <br /> signature and date below. <br /> NAW _ �G, ,l/� —T1T`Li",0�d0�-.' /�'re�,1�— PHONE#,., _7�9`7G✓=/LKS <br /> AC>I�Rf°4S ./•��(,!� ail!" 37. 0 .�IIIIeX-0'Z' <br /> 12 <br /> 1�I[?!300'.8(1-ovltu(1'_W..0/OJ) <br /> 1 <br />