Laserfiche WebLink
SAN ,..10 A Q U! N Environmental Health Department <br /> _..__COUNTY ., ._ RECEV❑R <br /> AUG 2 2 2017 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT EN PERMITISERVICESRONENTALL <br /> THIS P,TeRMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> [I TANK RETROFIT PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# C AROO O O To 7 Project Contact&Telephone# SeSse D-%0\1 Hos-(- 91-16(0 o <br /> A <br /> C Facility Name `Oq e'S C OUh�v4orc- d f C & ]W -3 Phone# -Loci-599- o-�y c> <br /> � Address S $ 3 C-oho►-� t� 0 C&A <br /> Cross Street C- 0 I or, o`CK Z ol <br /> � 01-0 C.-C\ <br /> T <br /> Y Owner/Operator ( V e-'S C vh4✓,\I 6-F C Phone# os - 6 R -4-166 0 <br /> ° Contractor Name r A (L L, Vv A`�A) G. 'I-\t�-,ev S o✓� Phone# Z p q - 4 (� _ 7 S?3 <br /> 0 <br /> T Contractor Address P ,0 CA Lic# S 10 7)---T ( Class C 6I I D7-1 <br /> R Insurer Work Comp# - .- c-&I LI <br /> A rC t e►'h h t Ca ar txew. <br /> T ICC Technician's Name Expiration Date <br /> T Curl w�• to enr��rson p -1 3o Zot re <br /> °R ICC Installer's Name ��•+-I � eExpiration Date <br /> 7/3d Zot� <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 piping sump,91 leak detector,UDC 1/2,etc.) / Installed <br /> T Srt� /►ALL a.0 () U0 <br /> A <br /> N <br /> K <br /> P ❑ Approved I Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A / O- <br /> N Plan Reviewers Name c �, � 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." ^ / � <br /> Applicant's Signature v Title V1 YtM ��`� / nh ate O l /2-01 <br /> BILLING INFORMATION: <br /> Indicate the responible party to be billed for additional EHD 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. /L (� C <br /> NAME )C S S� IJ l `1 TITLE �hy�rGv�►,^e..}r. /y1`� HONE# '[C)J 6 �� U �' D <br /> ADDRESS �• d- PGx ' 6 6 0 C <br /> SIGNATURE DATE <br /> 2 of 6 <br />