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1N <br /> Y <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 100 DAYS FROM THE APPROVAL DATE. INDIGA'rE PERMIT TYPE BELOW <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIRIRETROFIT D COLD STAROVEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Carrie Miller 209 461 -6337 <br /> G Facility Name Wight Holdings Inc . Phone # <br /> I <br /> L WAddress 2908 . Benjamin Holt Dr . Stockton <br /> Cross Street <br /> T — — <br /> Y Owner/Operator Lawrence Wight Phone # ( 209 ) 993_ 7825 — <br /> c Contractor Name Elite IV Contractors ' Phone # 209 -461 -6337 <br /> N Contractor Address 2535 Wigwam Dr Stockton , Ca 95205 CA Lic #1001331 Class A -- <br /> i <br /> A Insurer Midwest Employers Casualty Company work Cornp # BNUWC0133392 <br /> C ICC Technician ' s Name Expiration Date <br /> T �— - <br /> RICC Installer's Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST : <br /> (La. 87 p p ng sump, 91 leak detector, LIDO 112, etc. ) Installed <br /> T slp Qo wilk 12 , 00 gut regular unlzc4dO _ y / IaGq: . . j <br /> A U11 UCK3 <br /> N <br /> K trGir,91Mr) %101P <br /> f <br /> P U Approved Approved with conditions 0 Disapproved <br /> L (See Attachment With Conditions) <br /> A 202y <br /> N Plan Reviewers Name Datelow <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OFSAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING : 11 CERTIFY THAT IN ' <br /> THEj PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS 1'0 BECOME $UBJEOT. TO <br /> ORKEWS COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOVNNG : "'I CERrIFy I <br /> THAT IN THE PERFORMANCE OF THE .WORK;FOR WHICH THIS PERMITS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENiAtiON LAWS <br /> OF, CALIFORNIA." <br /> ate <br /> [Applicant's Slgnature Titte Office Manager _ _ <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be . billed. for additionAl THD staff time expended beyond permit payment coverage per . <br /> tank , If the party designated below is different than the permit applicant , e .g . property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. I' <br /> D <br /> NAME �;� WrL ( � i � ll ( TITLE PHONE # Zcw� iCI ` � Z. ri <br /> AIJDRESS l G� VTI" rJ ( (%o l '6 (o)-(Lt'vu S IT Li.L fZ1J `7 1 L <br /> SIGNATURE ` vlivv� G-{Z�— — DATE <br /> I <br /> 2 or 6 <br />