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SAN JOAQUIN Environmental Health Department
<br /> _ COUNTY --
<br /> APPLICATION FOR UNDERGROUND STORAGE TANK
<br /> RETROFIT OR PIPING REPAIR PERMIT
<br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW:
<br /> ❑ TANK RETROFIT YPIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE
<br /> F EPA Site # Project Contact & Telephone # etylig ( G Zt (A) t
<br /> Facility Name '' I ' Phone #
<br /> O 1 1
<br /> I Address t q ,Z �, 7 �td` D v
<br /> Cross Street r ,
<br /> T
<br /> Y Owner/Operator 'aCch ` fir( v Phone # 67tY) 76
<br /> — �tf
<br /> C Contractor Name � � r ✓ Cc
<br /> Phone #
<br /> T Contractor Address 601 ( St CA Lic # 9 0a, Z
<br /> Class G
<br /> A Insurer , t �ChJ >✓ CS C Gi Work Comp # '� C /} 1 �cyv a
<br /> c ICC Technician 's Name S Expiration Date C:
<br /> T ov) II. 1 C t C W c s.
<br /> R ICC Installer's Name o✓tk", LC U Expiration Date /Zp,?U
<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 3NIrfr clue. f0 EK5, 20 K 17 CC %& C C'•jU ✓J' k 'fe, w
<br /> A
<br /> N
<br /> K
<br /> p ❑ Approved ❑ Approved with conditions ❑ Disapproved
<br /> L (See Attachment With Conditions )
<br /> A
<br /> N Plan Reviewers Name Date
<br /> APPLICANT MUST PERFORM ALL WORK IN 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: "I 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 Signature ��� / y Title C V Date
<br /> RII_ I_ It\IG INIPORMATIONI :
<br /> _ - • : . . . , , n� • ', c , -� ^' r+r' '� n�/nnr' �r� rm :a npymPn,. Coverage Der
<br /> n., .-.Y :_n '�I� •� • " nr rn. ., r r - _ , . _ , _ _
<br /> .... . . . . . r _. . .., r, .,, , . j .. ., .; : y . .. ..�. :. .. ,il.l\ , :i . , , , .. .: . . . .. .. , , „ � ri:., i , . , , u �i r. : ,. .. , , 6 . y . F' • Jr., 'oliy .. . .: %: l , 1� ! EJ 'pJL 'i'f inJSi
<br /> acknowledge this responsibility for the billing by signature and date below. )
<br /> NAME CfCr` t SSal/ t TITLE I /I ( 1 � {' f CS 17t C ✓I, PHONE # 71Y - 76 1 ' s�✓
<br /> ADDRESS oZ � �iQ Al ✓ g IUC C e20 b
<br /> SIGNATURE . '�" DATE 1 -2f 7G ( f
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