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Dec,22 09 12:21p Elit V Contactors 12094642 <br />ENVIRONMENTAL HEALTH. DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 East Main Street, Stockton, California 95202 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />p.2 0"D <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 18D DAYS FROM THE APPROVAL DATE. INDICATE PERMITTYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />A <br />C <br />Facility NamecluwnPh <br />ne # <br />L <br />Address 5. 5M. <br />TCross <br />Street <br />Y <br />OwnerlOperator <br />Phone # 209 465 -6171 <br />C <br />0 <br />Contractor Name <br />Phone # <br />T <br />Contractor AddressdL)i t CA Lic #r��- Class <br />R <br />A <br />Insurer Work Com # <br />�" Co ii jn rgNteL �ktn p y y <br />c <br />T <br />ICC Technician's Name Expiration Date 1` �1 <br />fii 11Ci1 PCrI i�hQiVl p 01 ©G�SPY ac�fo <br />oI <br />R <br />CC ' <br />Installers Name 4i a Expiration Date <br />Tank system work area <br />(i.e. 87 piping sump, 91 leak detector, UDC 172, etc.) <br />Tank Site <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />T <br />A <br />N <br />K <br />P <br />❑ ApprovedApproved with conditions ❑ Disapproved <br />L <br />See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name, Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH 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 SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE J FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA," <br />Applicant's Signature Tide <br />MILLINQ) INI-UKIVIA I IUN: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAMEA 1 ty Col0.V 1 TITLE. PHONE, -26c) <br />EH230038 <br />1 <br />TE I4ZZ( 1 <br />