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SAN 1 O A Q U I N Environmental e� E Ej <br /> — COUNTY <br /> JUL 0 3 2020 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> PERMIT/ SERVICES <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMI TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site # L 00 © 3 Z3 �f * 0 Project Contact & Telephone # C2 09 S" q _ t-j �? ! <br /> C FacilityName AiO. 00 A etM 4 • /I$� Z 6 0 2, Phone # czo`i 830 <br /> � Address 2430 . ) 0C 1 " bM bo 19Ak, 'I CA q 3A <br /> TCross Street t R 2,tevt • <br /> Y Owner/Operator � r ,1 � �, Na� cti. vt t � y Phone # Zp 5 � •• y01 y <br /> C Contractor Name Phone Z <br /> o ,D / av✓to"n� e • . dem S� 'v , ce5 It � c . 5 ) ) y 0 �z>Y03 <br /> N Contractor Address j (2f ;oC� �l{ qty p CA Lic # Class <br /> T <br /> R Work Comp # Ct' 2 / � 9 � - / � <br /> A Insurer S +aA-e C,� ,.. ZKa ` g � .. <br /> c ICC Technician's Name �'� ( e .e h e L Expiration Date 200 <br /> T <br /> R ICC Installer' s Name C,r & AcL( sc� z 1, Expiration Date L4 57 � Zca Z / <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T EIN7 <br /> S <br /> K • r3 0 13' 12 00 r I (jo 1C c9t-� 4 / moi' <br /> P ❑ Approv - jX Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> N Date U 112,62�0 <br /> Plan Reviewers Name i <br /> APPLICANT MUST PERFORM ALL WOR ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's SignatureTitle l U1 Date 2 <br /> � �03 � r, � t� <br /> BILLING INFORMATION : <br /> Indicate the responsible party 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 <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME soli TITLE x7121 PHONE # ZCA - $ 79 y 0 ! U <br /> ADDRESS - 7 � O 1`L� f a�✓t 0 Y � I 11 � —G rl C� 5S"371 <br /> �7 <br /> SIGNATURE DATE..0 / r0 <br /> 2of6 <br />