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HUMBOLDT COUNTY UNDERGROUND STORAGE TANK PROGRAM APPLICATION FOR PERMIT FOR Date Paid: .P,ARTMENT OF HEALTH AND HUMAN SERVICES .4w 1"0 )MSION OF ENVIRONMENTAL HEALTH(DEH) Repair/modification(includes leak detection 8 product lines)M eceipt t.__7-1-2 ' H STREET,SUITE 100 Install n REKA,CA 95501 ry osure nt: W7)415-62115TCm�o rarer Identify tank(s)involved: )Q-t Sy nT MJQ.� t Application is hereby made to the Humboldt County Health Officer for a permit to construct,repair,or alter an underground storage tank,or for cknure, temporary or permanent. This permit application must be signed on all three signature lines by the same person,i.e.,contractor or owner/operator. CILITY NAME: Y a G]Ar_G G1I -PICItITV ADDRESS: C.'s 7y q NUM I cal: 1�.1 A al /1 ATY/STATEZP: Syrtp_I�(A 1 (�m�� Cj65V3 PHONE: ",5 QQ] 7f{O' OSS STREET: �/j�""�" rnnA�iQV C�1 C 0ic FIRE DISTRICT: S.�n�L_ �Q PD2IC!�l%/�LI.1YYLtcT WMERS NAME: klY1L&11 )WNER'SADORESS: 1'O n5•4 Q(n f.Yj7 YISTATEZP: SAA gaMOA CA 4LI68S PHONE: 2 ' 90 0 L. 1 • E )PERATORS NAME; Sp..r1{_AS rf..lni_i 'AERATOR'S ADDRESS: YISTATEZP: AME:_ PHONE:_ A 9 7NACTOR5 xsO( �C. -NTRACTOR'S ADDRESS:_ logo W(o Wasu A' Sony g9M896 .D DIV1S1C Z STATEP:_ �V l CA -I/,6S0( PHONE:_ t'I t I 0.7 - AL HEA rERMS OF PERMIT-Applicant Agrees That lumhoidl County DEH will be notified a m nimum of 48 hours prior to starting work _Iumbo(dt County DEH inspection will be obtained prior to backfilling and/or covering the work(where applicable). 1)ANY DEVIATION from the approved permit without prior approval from the Humboldt Counly DEH may be cause for stopping work until the changes are fully justified and approved. Phis permit is subject to revocation if found to be in nonconformance with Humboldt County Code,City Codes,or standards of the Humboldt County DEH or State Underground — Storage Tank Regulations. L'- c c i)I,the undersigned owner/operator/applicant of the subject facility,hereby authorize L/1 V\IJDAR1Gy1Q2� �{,�� to release any and all analytical results,geotechnical data and site assessment information to the Humboldt County DEH as soon as it is available and is provided to me or any representative. lddificnal items: understood that the issuance of a permit in no way indicates that a guarantee of perfect and indefinite operation is made by the Humboldt County DEH. I hereby acknowledge 1 I have read this application and state that the above information is correct and agree to comply with all County and applicable city ordinances,and state laws regulating ?"round storage tanks. This permit shall expire by limitation if work authorized is not commelnced within 90 days. ('� ,/� �f Q l if gor CC..LtflG �yil l ) t undersigned applicant certifies the following: SIGNI�IRE OF APPLICANT ' "yes -1 Coastal Zone Permit Agency contacted,if project is in Coastal Zone. INTRACTTOORS'LICENSE LAW CERTIFICATE (Complete A or B) WORKERS'COMPENSATION CERTIFICATE (Complete A or B) —4 The applicant is licensed under the provisions of the �+ A. A currently effective certificate of Workers' Contractors'License Law under License# Compensation Insurance coverage is on file with the and said license is in full force and effect. Humboldt County DEH,Policy 3by32q -00 —B.The applicant is exempt from the provisions of 0o B.( certify that,in the performance of the work for Contractors License Law for the following reason: which this permit is issued,I shall not employ any 1)Owner/Operator person in any manner so as to become subject to the 2)Other(explain) Workers Compensation laws of California. tTd@1f ,, xi k '" ]ci55� 11-26-f-02. APPLIAn DATE: APPLICANT VDATE AN APPROVED, t/v1 rAM j TE: 4146 0 tD 60 WORK APPROVED: DATE: %PIRATION DATE: "N4 TRANSFERABLE WHEN APPROVED,THIS IS YOUR PERMIT UST 412002 (Page 1 of 1)