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r-- <br /> a <br /> REGEN', <br /> a <br /> Environmental D artTgnSANAAQUIN rl <br /> COUNTY— <br /> APPLICATION FOR UNDERGROUND STORAGE TANkNVIRONME TAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE_ INDICATE PERMIT TYPE BELOW: <br /> LTANK RETROFIT R PIPING REPAIR/RETROFIT UDC REPAIRIRETROFIT 0 COLD STARTIEVR UPGRADE <br /> EPR.Site# Project Contact&Telephone# R(1,11 Ice, ¢- <br /> r� — <br /> FacilityNad Phone# <br /> me <br /> _am l <br /> II Address 3 �a C IO (2�t 92 , CA 9 �-366 _ <br /> Crass Street <br /> Y Owner/Operator Phone# <br /> c Contractor Name I a V.,«,,,,fit (2 le,, SU A 6e4 ��_ Phone#(-7 2S <br /> C) <br /> Y Contractor Address -741q C t - OC� Gg �r�3 ort CA Lic# Yc( Class <br /> R Insurer , Work Cam # <br /> A cZ C0� eKsa4r'�- '�+ �vnd p Zf Y�S� ! <br /> GICC Techr ician's Name �' Expiration Date <br /> R Exp;raGanDate <br /> ICC installor's Name i t - <br /> �vC.�Qt � <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (1-x3.87 piping sump,91 look duiaeor,UDC 112,atc.) Installed <br /> A <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Oisapproved <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 /> OAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT. OWNE=R OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT iN <br /> THE PrRFCPhW4E 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 /> WORKi:R'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY <br /> THAT P4 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS <br /> ,OF CAJFORNIA.' <br /> 1 <br /> AP131iCsit'S 51gn�,iuPa, � f`'CJ � l.- Ti!!e _._ ." Dale ?2,6 - - --_-=- <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 /> NAMt: f\r� r ! Ae'TT_S.,J 6,11 TTITLE ull PHONE# `��l�-S ?�j t l q <br /> SIGNATURE .` 1 �. YE'r. LT --- DATE <br /> 2of8 <br />