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BILE <br />ENVIRONMENTAL::- HEALTKEPART:MENT :u= <br />A L-. AQ --INN- C71JN--'._:_. _ <br />SZQ.Q_�.�;zt.Main tr_e t,_St�cktop,.Callfbinia-052.02.. <br />_ . '........ _................. - <br />-T-6-6 hong (.09. L46$=3 <br />i4TIONFOR-UN6EffGROUNU-WORAME-TANFf=_-:_:::_T___..::_:.:__.__.____ <br />= - -- __------------ -- --= �hETR01 IT OR6PIPINGPI EWA1WPERM•1=T ..._.---,--- <br />_.._. -THIS PERMIT EXPIRES'180 DAYS FROMTHE APPROVAL DATE INDICArEPERMiT rYPE sELO1Ni '- <br />❑ TANK, RETROFIT ' ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIRIRETROFIT ' ❑ COLD START/EVR UPGRADE <br />F . <br />. EPA Site, # I. <br />Project Contact &Telephone #: <br />'!�' <br />A <br />....D._--Faellity'--Name <br />...� .. .. . ...... .:. <br />- ' � <br />-Phone!— _ ._ . � ... - <br />1 <br />Address <br />bn 15 <br />_l..'- <br />T <br />-Cross Streef:.: ,.;....._ ...• ... ..... _ .... ......_...... _...... .............._...., _ <br />Y <br />Owner/Operator 6A Plf I PM DA <br />Phone # i <br />c <br />Contractor Name <br />P► 6he # <br />T <br />Contractor Address <br />GSA LIC # Class _.. ,: . <br />, �j <br />A <br />Insurer a <br />Work Comp # <br />T <br />ICC Technician's Name <br />'. <br />Exp(rafion Date <br />Q�...-ICC-Iftstaller_s_Na <br />r�- :. ..........:. .. <br />.Tanksygtem work areaDate:. <br />(I.e.87plpingsump;91leak detect or,UDC 1n,elc.) <br />Tank Size <br />Chemicals StoredCurrePitl'Y <br />UST. _ .• <br />Insfalled <br />T <br />A <br />N <br />K <br />P <br />F1 Approved, Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />. <br />nn <br />Plan Reviewers Name @"Q MaR Date a <br />APPLICANT MUST PERFORM ALL'. WORK IN ACCORDANCE WITH SAN JOAQUIN'COUNTY ORDINANCES, STATE CAWS, AND RULES AND.ffEGULATIONS OF SAN <br />JC-AQUIN.000NTY, ENVIRONMENTAL HEALTH DEPARTMENT;. OWNER OR LICENSED'AGENTs SIGNATURE:CERTIFIES'THE FOLLOWING: "I CERTIFY THAT•:IN <br />QR{�, t GE OFu . 0 EOR -W .,Ile}i-4� q-eEf�MjGj:I51SSUED� I,SHAL .-(yOT EI�P�QY [JY`PER�SON IN SUCH'A.MANNEE3;AS'.TO BECOME:SIJ9JECT TO <br />WORKER'S 00MPEft" '.WL�AW <br />RNIA" CONTRACTORS HIRING OR SU13CONTRACTING.SIGNATURE CERTIFIES, THE FOLLOWING; "I CERTIFY . <br />FLAY iN i 'r�ER�OF(tu1ANOE OF FHE WOt2M 0 i WHICH Tl IIS p RM1T I UEDa I SF A, EMPLOY PERSdNS § ij IE.CT;XQ Il1lAE ICEIiS.COMFENSATION: l AW9,; ., <br />,IS <br />Applrcarit'sSfgnatUre ... _. Title . Oate _.___._...... .. <br />beyond:permit pa Ment -b Wdeg a=por:tank: 1f_..:: <br />Y �- <br />ahe .party; deslgnated below Is: -different' than .thy :permit applioarit, e.g. property, owner,. the party •must.-abkh6W1edbe this .. - <br />responsibilitY for the blliing_byaignaturg anq date�i o <br />-... NAME (�r�-►i�a� ":Y,� 71TL' �� - PHONE <br />AbDRESS .:. Ff�'� NP. <br />iOQNAU'E=. M— N. <br />. <br />EH230038 (revlsed 08/1/11) <br />2 <br />