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REGE V �f .,'yam' D <br /> s N O #Jl+ i s.? r121IBi7tG 13 � Pkr L LI F� 61t <br /> —.0 ; P Im I + <br /> APPLICATION FOR UNDERGROUND STORAGE TAS ' (O1 �1d � 1 ', � . � 1EAL <br /> RETROFIT PIPING REPAIR I ,_,� �., €P�' IT W ei lf <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOIAI: <br /> El TANK RETROFIT J PIPING REPAIR/RETROFIT tI UDC REPAIRIRETROFIT Li COLD STARTiEVR UPGRADE <br /> F EPA Site # Project Contact . Telephone t`k `' w <br /> AFacility Name ^ +,�� -- – :-._ I .�13 ,* <br /> — -- — Phone <br /> L Address <br /> T Gross Street <br /> --- __ <br /> Y Owner/Operator '— — - - Phone # <br /> € € . ✓ <br /> nI Contractor deme ✓ c t� ' — - -- -. -- r� r <br /> _— _ --- - � &w r.� � � f r e14AA2`' i Phone ## <br /> N - ------ 67 <br /> Contractor Address '` <br /> Ensurer <br /> *A Lic # _.—_- <br /> R � • — Crass <br /> � �. <br /> Work Ccmp # 907;6o <br /> IT ICC Technicians 'Name Expiration Date <br /> :� - -- tom} <br /> R ICC Installer' s Name <br /> s Expiration Date - s <br /> Tank sysiern avon< area —T— ---- <br /> < <x87 n=Nn{r sump, ) t ie0ti_ ea:�a�:. uTank Size CrhenTicais Stored Currently Dat US r <br /> -- .. Insialled <br /> A <br /> N <br /> P Approved Approved with conditions Disapproved -- — <br /> A ( See Attachment With Condit ons) <br /> ry <br /> Pian Reviewers Name_ Da <br /> tee <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAGQUIN COUNTY ORDINANCES, STALE LAW,,, AND RULES AND REGULAIIIONS Or- SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTIVIFNT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLONJTNG: "I CERTIFY THAT IN <br /> TTHE PERFORMANCE OF THE WORK FOR W-ITCH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PrRSOtd IN SUCH A htiANNER AS TO BECOME SUa EGT TO <br /> HAT I T PERFO ,SgT{ON UiINS OF CALIFORNIA ` CONTRACTOR'S HIR NG OR SUBCONTRACT1,z1G SIGNATURE CERTIFIES THE FOLLOrANrS. "I CERTIFY <br /> THAT THE PERFORM OF Tit[ WORK FOR kAMICH THIS PERMIT I S ISSUED. I SHALL EMPLOY PERSOitS SUHJECT TO +t✓ORKEP,'S CO49PEtJSRTION LA'P5 <br /> Ot= CALIFORNIA,"LI4 r" <br /> Tide ,� ,�- ,.. � . <br /> r e <br /> -----` ...+.. .r c.-- a rata J S2,. <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expender' 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 belov✓. <br /> NAME <br /> TITLE L _ <br /> — <br /> ADDRESS <br /> SIGNATURE ' <br /> i ' 7 <br /> I 2t ; u <br /> i <br />