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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 100 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW' <br /> TANK RETROFIT 0 PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # flao I ee -jt- 5i w q <br /> C FacilityName AACO &&A ,pM tt y ,.?d' 3 I Phone It Z 0 9 5 meq, - '-(OI y <br /> I <br /> L Address ) QOK SCS ✓11 � 1_ 3'� pi aAij1_'. cC� CA 9 533q -- <br /> T Cross Street �L <br /> _ <br /> Y Owner/Operator ," ee t- S 1 V {` . Phone # UoS ` 5 1 `/Dl `( <br /> Contractor Name D , � t p �Cv.� rvr cC� Phone # S' Z� !{ 46 - 0 x'03 <br /> o - <br /> T Contractor Address 36 5 k i " C+ R v1 h Oc t% C/-) 9yy )o �j CA Llc # 1QOS y y Class <br /> A Insurer s C� } C `,�� Y' lytS c-F,�1,. �I gW2o+Ce �yg Work Comp # q Z1 9 ?3 1 i <br /> T ICC Technician's Name adq � <Samelle Z Expiration Date y _ �_ zv "L f <br /> R ICC Installers Name v G da ^Q - �t C, Z Expiration Date �- - ZO 2 1 <br /> Tank system work area V Tank Size Chemicals Stored Currently Date UST <br /> (l,o, 87 plping sump, 91 look dolodor, UDC in, otc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P LI Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A ` 1 <br /> N Plan Reviewers Name Date <br /> APPUCANT 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 ' L� <br /> Applicant'sSignaluro 1 / `- Ti0e Dato 0 1 '16 r l <br /> BILLING INFORMATION : <br /> indicate me responsible parry to be uiiiedior addMunai Unu stalitlme 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 X 0 rr ox % f+J o TITLE C/v PHONE a 247'1 So) ( i d y <br /> ADDRESS 272 CA e/) X5'3 3 '7 <br /> 1 , <br /> SIGNATURE ` � o 44 <br /> � � f � �4 I <br /> 2 0l 6 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> I <br />