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Jul, 10. 2008111 : 38AM ---"West Star Envi ronmenta1, Inc, No P. 1/2 <br /> 15 AW <br /> ra. L <br /> i�fllaOT� i <br /> ENVIRONMENTAL ��HEALTH DEPAy �" <br /> SAN JOA a G <br /> V <br /> QI�JIN COiT.ty T Y "�- <br /> 600 East Main Street,Stacktan�California 9$202 stir <br /> Tckphotee! (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND ""OP-AGE TANK RETROFIT OR PIPING <br /> THIS PERMITEXPP�IRES 160 DAYS FROM THEAPPRovAL DATE INDICATE bERMITTYP� O <br /> W. <br /> AREPAIR PERMIT <br /> L JTANK RMOFtT I IPIPING REPA,.,TRQFrr �/ <br /> DC ItEPAr <br /> { EPA Ske# � `""- --� W ROirT ^~COLD sTART/EVR UPCRADE <br /> A I-- �......._,. p^?Ject ContaCt&Telephone#�f'J� q <br /> C I Facility Name S� m. �V 778 <br /> LAddress !1L1n !='f' Phone#0.JCjc} <br /> en r , <br /> I Crosa$IfCet <br /> I T <br /> Y dwner/Operator � ca�'t — <br /> o Pho <br /> Contractor Name( „41.. _ Phone# _~ <br /> TContractor �r 1 -�_ .177• ✓576 <br /> R Address !�- J CMrW RC.r-- � /U CAUc# C�� � o� Cla" <br /> Insurer <br /> C Work Como#C L450c;-?L4 j <br /> T 7—IC'Cinesctauces <br /> nician's Certification Number 525`7 c) piration Date _ �'� Q`� <br /> Certifiwtfan NumberRExpiration Detm <br /> I Tank ID# Tank Size ChCurrenNyln fly/a StoredpreviouslyDate UST Installed <br /> T Ci & <br /> N <br /> iApproved Approved with condlbons M Oisapprovao <br /> L <br /> P (See Atf�Chment With Conditions) <br /> rA -7I <br /> N Date <br /> Plan Reviewers Name,— <br /> AND RULES ANO REGULAMONS Or-SAN <br /> ApP)ICAM MUST pStFQRM ALL WOR EALACCORDAW TH pEPAFCI MENTTOWNER OORH SAN CLIC@NBED GNrS SIGNATURE CERT LAWS, <br /> E3 TFFE mrmR A FOLLOW44-1: COMECERTIFY T"ATSUBJECT TO <br /> JOAQUIN COUNTY,rzWRQNMF.NTAL H <br /> THE PERFORMANCE OF THE WORT(FOR WHICH THIS P£Rma IS ISSUED,I S11lUd.NOT EMPLOY ANY PER9QN IN SUO►I�►MANNER AaRTIFY <br /> S TO BECOME SUB}EC <br /> WORKETt's COMPENSATION <br /> LAM <br /> O WORKFOriNIFOR v- c til Pt=TORI HtISSUED.1NG RI Si1ASl���OY PeR�S SUE3ECTT CERTIFIES <br /> CO IN�nQ UM <br /> THA / <br /> QC CALIFORNIA" <br /> Title <br /> ! �yF^ ,�s�"-°t>,r 13ILLING INFORMATION' <br /> IndicatC the responsible party to be billed for additional FHD st@lf time expanded beyond permit payment party mustverage per <br /> tankttils <br /> the party designated below is different than the pefmit W g- property <br /> y on <br /> responsibility for thebillingby Signature and date below. /7 !� <br /> NAME +*•`G11'___^__— t TITLE PHONE M — I 't <br /> o oSr✓h-v f <br /> ADDRESS p <br />