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i <br /> A I (9 Environmental Health Department <br /> SUIN <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 D PIPING REPAIR/RETROFIT D UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # �ah At656 W 5"0 49 Z,. 70 16, <br /> A Facility Name 26oa 'Ttzzcy Sa Feway � �er Phone # Zo7- 630 9q <br /> I <br /> L Address ? � � k/n. !lam 5hc� � ) 1 m_y CA 1?5376 <br /> I Cross Street F(a[le ( <br /> T <br /> Y Owner/Operator j z� Phone # <br /> C Contractor Name ( / Phone # S;b9 <br /> N Contractor Address 37 L'Z e, AvgF� "e CA LID # 9556 x-(og Class A <br /> T <br /> A Insurer lnvlL' ems 5M (P_ / y k� Work Comp # � p6 '32 5 <br /> T ICC Technician's Name ll j&4�1 'n (o Expiration Date ` - 2 g Zc72U <br /> ICC Installer's Name In {� " eme2 Expiration Date R_Z4- Zv72z <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> 0.9. 67 piping sump, 91 leak deledor, UDC 1120 etc.) r7 pp Installed <br /> ADO �alw3 ,t; dAirr- �B5 <br /> RT <br /> rA ) 01040 j.+ff �S�I <br /> N <br /> K hU "o FC2.mt` Lt <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L 7 (See Attachment With Conditions) <br /> N <br /> Plan Reviewers Name If Date ° <br /> APPLICANT MUST PERFORM ALL WORKIN AD RDANCE 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.n CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 01 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 �*-1-�Cs ""�`` "1 rua f ,Wirer- /l'� -�*. <•:y Date <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 appticant, e.g- property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME I klh t � tC lois'. t4 (I+cr A TITLE 1 j'ogef /4&yf, w PHONE # <br /> ADDRESS 2 .' C r k7 or. � � XeN,ge r j Y7s a:.u � / GJ7"I 7'1Z0 -&" <br /> r a <br /> SIGNATURE tf`'C �"- �. CL'-r. DATE <br /> 2of6 <br />