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' FROM :Donlee pump r_o. <br />FAX NO. :2095379390 qug. 03 2007 11:00AM P2 <br />08/03/2007 FRI 10:48 FAX 2094683433 SJC ERD <br />002/002 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUV'I'Y <br />304 wast Woher Avenue, Third Fluor, Vt'Ocktoq, Calfforpiia 95202 <br />Telephone., (209) 468-3420 Psm, (21Ia) 468-3435 <br />APPLICATION FOR UNDERGROUND STORAGE 'YANK RETROFIT a� PIPING REPAIR PERMITkf'n'• ` THis PEIgMIT EXPlrtrt 50 DAYS FROM 1'H15 APPROVAL, DATi,, INDI ATE FI:RMIT TYPt gLl..Qw <br />�A�°1 I I'rANIC RI I{UFIT L�F'IPINC REr'AIR/RETftOFI'1' <br />_ �clr)c REPAIII/RnTROFIT <br />r EPA situ 4' L - — _ - _ _ <br />A 0 2 7: Projoet contact & Telephore it %�� _ 9"Y- <br />` S S Y <br />C Facility NeirnaL AddhaSS , �Lz Per, <br />�iG' �� � <br />Cross stmAt — <br />T- --- - - <br />Y Ownor/Opereftnr — .-. ,. <br />G Contractor NameO - <br />.... rr Phv 1®0�� � <br />N <br />TContractor Address I ., <br />- <br />�,� Asr i" rLl CA LLC# �/ <br />R InsurerC� �• _ <br />i._. <br />A !.t>r►t �ne11 W0111 COr7tp rW�<:a�9/`►�3 3�/(r> <br />T IGC Techntcl®n's Certification Nurnbor$Z %d !J 7` t?xpiratlgn (7eltc <br />U <br />R ICC trlufaller'e Cenifloetion Number <br />y� _ Explratk)h Date <br />Tarot ID # Tank Slze ChamicA 8 Scor®d -�Cate US7 Installed <br />Currentlywrmvintisiy <br />N <br />, <br />r <br />n r �%er'�•�`- 179 y�8 ..�3y <br />N 1. iAppnnved �IApproved with c-nmtions [ '1Cisaparoved <br />L <br />A / (SAA Attachment wHh Condltion;i) <br />N Plan RevloweTs Name 1/'-!I <br />APPLICANT MUST 911EIR CORM ALI. WORI( IN ACCOROANot" W1711 GAN JOAQUIN COUNTY Op.0114AN(;95, 8TA'I a LAWG, AND HIJI,I'.5 AND r112SULATIONS OF AA <br />,)OAC)UIN COUNTY, FNVIMONMENTAI. FIE'AI.IH DL-PARTMENT. OWNEN Or I,IC,ENSED AGEhrrR SiraN',T(JRE C:tKIIPiCS 1HE FOLLOWING, "I GI.RTIrY TIIAT IN <br />THE PERF OIRMANCr OF THF WORK FOR WmICH CHIS FkNMIT IS ISSUED, f SHALL NOT CIAPLOY ANY F ERSON LN aur;t f A MANNLK AS TO f3r-COME9UNJr--C ' 0 <br />WORKP-R'S COMP14NBATION LAWS OF CALIFORNIA ,^ M)NTRACTOR'S ttIRIW OR SUBCON1'14A(;TI�G "GNATURR Cf-dATIn11'� TI'IF FOLLOWING: "f CERTIFY <br />THAT IN TFIs PERFORMANCIa OF THE WORtc f ORWHICN THIS PErRMIT IS 1SSUIM I SHAIJ EMPLOY rEH$c)Nu SUBJECT TO WORKF,'R'A r.nWr,ATION LAWS <br />OF CALIFORNIA." <br />ApplfaenU E�I�r)Nlrlrni �;. r � /' <br />BILLING INFORMATION. <br />Indicate the responsible party to be billed for additional EHD staff time Axpmnrind beyond permit paymRnt 00v9rmp pr9r tank. if <br />the party designotod below is different then that pal'mlt opplicelnt, a -g, pr'opetty twnoY, the party must acknnwlc�rtt�ra this <br />respon:;ibillty for the billing by sIgnature and dare oiglow. <br />/I!zxk4A L- lr ')'I l ILL rye A0,V'4refe- 111-10NE A <br />f1DDRESS O C 5�. (1 �rr`�`d�?)^'rte( ✓t� G�d'L°�i Cf� 1P 3rl ._ <br />2_ <br />SIGNATURE <br />LI.123171018 (rovioad 818/0$) <br />