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From: (949)460-5204 To: 12094683433 Page: 3/7 Date:9/20/2010 9:06:37 AM <br /> t-roan:VM3453 Page:W4 IJate:t3P31CLU1U 1 I:UILM ANI <br /> 1 { <br /> SAN JOAQUIN COUNTY <br /> 604 East Maim Street,Stockton,California 95202 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 980 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> dTANK REMF7T ❑ PIPING REPAIRIRETRoFIT ❑ UDC REPAIRIRETRoFrr ® COL.D STARTIEVR UPGRADE <br /> I <br /> F EPA sits c mgt Project Contact&Telephone#'` �C e •a.# 'l-`ix d-to <br /> C Favi ity Name <br /> I <br /> AddressjCi7.� <br /> L <br /> TCross Street <br /> Y Ownerloperator Phane# f <br /> oContractor Name ., ., ty Phone# I <br /> r <br /> Contractor A `?.S t-tt"�€x Iac C wreurz t. GA L1c# Class 44WQ, <br /> A Insurer, �a�caA1.l�W�t ata " C.x� , Work Comp#v.�=.-".ate?I 01.00 <br /> T ICC Tec hnlctan's Name Utw, , y'��,k,. Expiration Date^ M <br /> R ICC Installer's Name •° L` Expiration Date i I.W <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> ¢.&t 7Oft 01 tea;UDC gra,OW) Installed <br /> T 16 <br /> adSSft%-h- k�- <br /> A 9t c_4Ca. <br /> N <br /> K <br /> -----........................... --------- .......................................................-- --._.._._.............-- -.......... .......... . .------------..__.. ----.._.-............_.____._.._..._. _._._..._:.....-....-- <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment VVdh Conditions) <br /> A <br /> N Plan Reviewers Mame Date <br /> APPLICANT MUST PERFORM ALL MRK IN ACCORDANCE NTH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKER'S COMPENSATION LAWS OF CALIFORNIA"CONTRACTOR'S HIRING OR SUBCONTRACTING$K*94ATURE CERTIFIES THE FOLLOWING 'Y CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i SHALL EMPLOY PERSONS SUBJECT-TO-WOMMS C,OMPENSATM LAWS- --- <br /> OF CALIFORNIA.' <br /> aSignaiune Trite ' ` E>Eae tC3 �� <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff fine expended beyond permit payment coverage per tank. If <br /> the pasty designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility#or the billing by signature and date below. <br /> NAM—E—'-E ' G7(SP% 4SoKf urfluc. =XAVA A E# C°I'3PA�4W <br /> ADOREss 2.5°I 7 !i owN fi T12l� aaT�E?_t� ���►c�.t pQ2h i a <br /> SIGNATURE DATE G <br /> EH230038( ; <br /> This fax was received by GFI FAXmaker fax server.For more information,visit http://www.cifi.com <br /> This fax was sent with GFI FAXmaker fax server. For more information,visit: http://www.gfi.com <br />