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03/11/2016 1e:59 9162732548 BZ MAINT 82 03 <br /> HEG IVSD <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY MAR 14 2016 <br /> 1868 F. Hazelton Ave., Storkton, Califbmia 95205 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 ENVIRONMENTAL <br /> ucht�'L.1 ntIo4RT11/.�1*�tT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT" <br /> 'THIS PERMlr FxmP•s IN DAY9 rRom Tif APPROVAL DATE. wmATE Penmrr TwT 6FLM., <br /> O TANK RETRLorIT U PIPING REPAIi iRETROFIT i UDQ RI!PAIRlRETF 0rR 0 COLD STARTtFVR fIpmArw <br /> F EPA Site#1 — Project CcrtGact$TelF3phore# <br /> A <br /> � Fecafity A1ame - Phone# ` `�i�i�. <br /> Address '�`M jjk} <br /> TI Crass Street <br /> ownartoperatnr Y "1 .. rr,ane �'I ' F ' IZZ3Z <br /> C; <br /> Corrtfdetor hlamo r k t' _ 1 Phone# Lo` `+Lg 7 <br /> Ctsntractnr Addnss Z sW&rnCA Lic# ' CIasS <br /> A Insurer �1 t}'1 v 5 C �Z Wwk Comp to 13N 1nlC-U 1T5 9 z <br /> ICC Technician's Name Expiration Rata <br /> oICC Installer's Name <br /> R Ciet9 <br /> Tsnl�cyst&n work area DT <br /> po-q pro,of reek ar.V90 14,dz.t Tank Size C{�ectiGelB Storod Currently hate ate UST <br /> I <br /> T <br /> A <br /> K <br /> i <br /> P [ Approved pprovcd vitt)Conditions ❑ Disapproved <br /> L At ChrneW With Conditions) <br /> A <br /> N Plar;Reviewers NzFnAFIFU <br /> DANT MUST PERF",A PLL WOtINC�$AN3+JraTY ORDMdAN $.STATE LAWS,AND RULES X4D PX-4nu ATiom OF SAN <br /> JOAQUIN COLD Y.ENVIR'0VN1EMX,_HEALTH DEPARTMENT.RwNER OR LtCENSED AGENT'S SfGNATVRE CERTSF7Cw T14E FOLLOWING: 11 CERTIFY THAT rN <br /> THE F£RFORMANCE OF'i7tE vxm FpR Nr}iIGF!THIS pERmfT 15=UES,t SHALL N(:q FMPLOY ANY PERS.D&1N SUCH A sMANNM AS TO BECONE SUBJE-r r To <br /> WORKER'S t 0waNSATION LAWS OF CALIFOR141A." CONTRACTOR'S HIRING OR SU8CONTR4CTNG sr-MTORE CEF'1lFiES PIE FOLLOWING: 'I CERTiF7 <br /> AT tN THE PERFORMAfF.,OFTHE WOPK FOR WHICH TWS PEk IT 15 15SUEa,15RALL RMPLOY PERSON$13UUJECT TO WORKER'S COMPENSATrON+LAV1S <br /> OF CALIFOftNtIA.' <br /> Apdit�nts3lgrtatis5p '�it �........._. 71t1e t•3(�/�fi .41' Oaea -- •.- <br /> BILLING INFORMATION; <br /> Indicate the responsible party io be billed for additional EHO staff time exMded baWnd perm)payment voverage per tanL tf <br /> the party designatBd bebw is different than the permit applicant. e.S, property owner, the party mu$t acknawJaage mis <br /> responsb r the t ii signatuT and date below, <br /> ' NAND TFT _— �rly` -fir _ f'Nt�NE# � <br /> ARDRESS l� ✓� S V Y <br /> r <br /> SIGNAY0R6 ! DPtT <br /> EH230Da8 trevie$d lot A2) <br /> a <br /> eoa/zoo d a9sE aoeTd1a:iueA AAuno3 33ZZLVG603L 8Z Lt 91,00ZLlE0 <br />