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A.N JOAQUIN COUNTY , <br />ENV[RONMtNTAL., HEALTH DEPARTMENT. <br />304 E WEBER AVE 3PA FLOOR .. <br />$TQOKTON. QA 2202 <br />APPLtCATiON FOR LINOERGROUND TANK RETROFIT. OR PIPING REPAIR PERMIT <br />THIS PERMIT.EXPIRE$ 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPO OF -LOW. <br />•__TANK RETROFIT ;PIPING REPAIR/RETROFIT _UNDER DISPENSER CONTAINMENT REPAIR/RETROFIT <br />+--------- -- -------------------r---------- ----- .... ---------' - ------------------------" ---- <br />1 1•IPA EYTB•# I PROJECT CQMACT & TELEPHONE # - -- t <br />1 +---------=-----/^�..��..�.,.� ........... e:..-------- _....--------__� _..---------Jy} R -----i <br />i P I PACR.ITY.NAMEp h ((((/i p` /3 t PBo[2 # p `L. I� �- <br />- U <br />-- --- <br />I. L I CROSS STREET <br />^---.--____ <br />14+---�___________________�_ �._.._:___-__-_-_---_-_------__...... »-____- , <br />_."_..-__-.._gyp_^rte.../-.s..--_/-c-)--__-_--•� <br />! T i .OWN&RJC2ERAT0& �N s V� i PHONB #�R p'-' 0 U K:-" <br />I'E 6.J1 i <br />I C ConfTRACTOR'IiAAM1B t PROD # I ' <br />_.-----------She_=+_°''----`55--=---------------___... _ ala:-�eC�3 �- - <br />I N : camtACTOR ADDRESS Q �t aet I CA LIC N t CLA66 <br />I T +---------- U °. 1!�-- �Sz------- ------------------------ S1`--_ -- BiCJ� 1& 04toz 1 iG <br />--- <br />I R I XN9UR IIiI - <br />" <br />-_ "tl4!�e S Y� ( =�d4�--- - ----- <br />-- -- <br />C I O$HER INFORMATE t t <br />O i <br />I R ---------- ---'------- -----~-~ <br />-------------------- —--- r.. ------ ^*--_—___ ..------ ---............. <br />t i I PHONE # <br />+...11i,iii{i•{Illliitiii•iiiiiittllli----___._:.-.;-^--------------•,_......------------- ._..._—----------- —_.._.e.. -I <br />-TANK XD # I VJWX SIZE CHEMICALS STORED CDR92NTLY/PREVIOOELY I DATE UST INSTALL= t <br />i ! <br />39* <br />i T 139- I ! ! <br />i x l 29 <br />39- t 1 <br />t ! 39- i <br />+---tillli,il:Sit'ti.;tiltiititiiittiT:s:l:iii i, ii, I ,fjt llirtilr.itlIIIII{Il{Pl 7751, illi,tlt1111111:tllrr t Ill IlTn"TTI, <br />!AI <br />I LI _. AP7RoYED APPROVED WITHcosmYT4tM (9) SA <br />AIPPROVED i <br />i A i rA' �t RsaE ATTACHMENT WITII 4,.XTI.S) <br />3 ✓� ,L®^ i <br />N PT Aic REvxsetsti5 lCAh� !V . N BATE <br />- i"iIII <br />lii <br />( A7?914I CI,NT MUST: PERFORM ALT MaR3C IN ACCQRDANC6 �ITTid QAbt .YOAQOTN COUNTY ORpltzAtaC@5, STATB LAWS, AmD At7LE6 AND REGOLATxOiBs O8 I <br />i SAN JOA! -SIT CG01i2Y. 'ENVYRONl1QdTAL RL'AJeTR CBPAATMENT. 0l7N8R OR-T.ICEN6ED AtiENT`S SI6NATORE CLRTIFISS Tft8 9O%SDWYN®t °I CER$IFY <br />i TICAT IN 7x R13RBORMIiNCB OP xEE WORK FOR WHTCK THIS &ERMYt S8 YSSUED, I'SlLALT NOT EMPLOY ANY P6REasE YN 6UC1i A'FtRNNER AS TO i <br />i aECOi� ^Lpa <br />T TO WOeaER 6 COMPENSATIOR LRM& Oa'CALPFORNIA." CONTRACTaxre HIRING OR SQBCONiRACTING SIGNATORB CEx$xs4ES Tiiffi ; <br />HOLLtrI a'CERIFYfixNTR09NOER `S SAI7CtIDt LA{tS oA CALiPORNTA. " 1 <br />, I <br />j, inTITTnuTlAfn ntnI1111I 2i Tf1?!fi PhiR i <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed fol additional EHD staff time expended beyond permit payment <br />coverage per tank. If the party designated below is different than the permit applicant, e.g. property <br />owner, the. party must acknowledge this responsibility for the billing by signature and date below. <br />Name cue � Pho �0 S --d-13 0 <br />�U. � ddress �� b Q Uyl�l ��-. G,�.�aS-� Phone # '� 0 g <br />.Signature ll i - . <br />EH2soa3s <br />(revised 1 /31 /02) <br />