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"' T <br /> Enviro�imE Hula '8eprtle <br /> E D <br /> SAN JOAQUIN <br /> - COUNTY JUN 19 2020 <br /> APPLICATION FOR UNDERGROUND STORAGE, P% NMENTAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERM] DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT . ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Pam qas 509 - '�8 Z �7o J6 <br /> � <br /> Facility Name 176 ? 5 7BWa FN >c GejPir Phone # <br /> Address 7.$ 07, CpK ..'Ec C111, 9Va/A • 54ek46KCA <br /> I Cross Street f;K+ftk0. "" (P <br /> T <br /> Phone # <br /> Y Owner/Operator 564e <br /> l 208 -345 « .S'¢ Z�- <br /> c Contractor Name Carmjtsto c R4 "+ Jewo Phone # ;04?' 4$ 7,. 70/(0 <br /> 0 <br /> N Contractor Address 3 � Z 6 L . I�o+►n! �Ve+ CA Lic # �J`�0 Zb 8 Class A <br /> T <br /> R Insurer �' R Siaf Work Comp # JQ67J <br /> A <br /> T ICC Technician's Name Iq wt Uy or Expiration Date / 2 -Z9 ^ 20 7.0 <br /> R ICC Installer's Name /Jwaf C04WAAev Expiration Date <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 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L Be Attachment With Conditions) <br /> 4 <br /> N Plan Reviewers Name RC'Li Date <br /> - - <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORD E WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS 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." C <br /> pplicanfs Signature � <br /> Title � �a 0`+ ` 4 y r Date 6 — 1 9 " 2 07.0 <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 11o" Gt <br /> � L2 � - [� LI '+ TITLE [fO� t � r1 �" ^Q � ar PHONE 047 <br /> ADDRESS 37 7 L Onh 0 { 5 J0 Vti.4e� o (AJn <br /> t2r> l/� 14�i�^�/ \ <br /> SIGNATUREDATE_ <br /> 2of6 <br />