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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />600 Vast Nhin titreet, Sttu•Ltun, ('alili►rnia 95202 <br />Telephone: (209) 468 3120 1'a c: (209) 468.3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THISPERMITEXPIRFS 100 DAYS FROM (fit APPROVAI OArt INDIGAII P[RMIr TYI"t I'll IOVY <br />I I TANK RETROFIT I I PIPING REPAIR/RETROFIT XUDC REPAIR/RET'ROFIT ffiCOLD START/EVR UPGRADE <br />FF EPA Site i1 I11oloct CUNt.lt,t R leletrhono tl t)�, InJCFZTr�i"6► Z-�t <br />O Facility NameT£Sp;�-� .� 6�'�-� I Phone tt�lra C,Z(� <br />L Address liOI WIF- r KE--VVL-f -Na+..J LA-tiv—1 LoD 1 CA `q::�L2440 <br />1 - <br />T Cross Street S0•1T, <br />.V-- L, _ U I� <br />--- - - - <br />Y <br />Ow-n--er/O-p-e-r—ato_r T---�., <br />.� done tr,,,,Z lo_ <br />o Contractor Name �QL£ f��It i� NP,t�aC� I t Phono # —IQ <br />N <br />Contractor Address , �!� iZ (n►O �tL R42 tc l�AC� ,I GA tic tt ��� Class C-I� <br />_... _ <br />A Insurer Work (om ati <br />, (tV S, vt.1p F q(0 -7 32 19 <br />T ICC Technician's Name Expiration Date <br />--- _. <br />R ICC Installer's Name Expiration [)ate <br />Tank system work area Tank Sire' Chemicals Stored Currently Date UST <br />(i a 87 piping Sump, 91 leak detector, UOC l i,2. eh; ) Installed <br />T Fits-r�►J(.,� VS i S fib 7 -v --,P4 _ <br />A <br />N-- ----- -- --- <br />K <br />P Approved Approved with conditions Disapproved <br />L <br />A - A tm <br />achent With Conditions) <br />N Plan Reviewers Name_ <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATL LAWS, AND RULES AND REGULArtONS OF SAN <br />JOAOUIN COUNTY, ENVIRONMENTAL H/CAI <br />ARTMENT OWNER OR LICENSED AGENT'S SIGNATURE CER nFIES THE FOLLOWING "I CER rIF`/ 'THAT IN <br />THE PERFORMANCE OF THE WORK FOHIS PERMIT IS ISSUED, I SFIAI I. NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS ONIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WHICFI THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA " <br />BILLING INFORMATION ` <br />Indicate the responsible arty 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 acknowledge <br />this responsibility for the billing by signature and date below /-Lt ;�� <br />NAME F Y S � N� IiJ£ Fi�Lt IJ� _ ITLE_��i��^"+ 2.'r�S7._`PHONE # b� I <br />sAt,,o CUS vj tzo p, � , sf� " WI <br />P,00RESSo'?F�440S <br />SIGN;'1TUP.f- ---- <br />EH230038 (revised 07/22110) <br />yam <br />