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SA N s10 A Q U I N Environm ment <br /> — COUNTY— <br /> IJ <br /> APPLICATION FOR UNDERGROUND STORAG TANK U6 / '1v''► <br /> RETROFIT OR PIPING REPAIR PERWVV, ®Z� <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE B�,cp��'V4, 1 <br /> TANK RETROFIT D PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT D COLD S`Y44 U! <br /> F EPA Site # Project Contact & Telephone # Ra vt <br /> A e, S, y k <br /> O FacilityName A. Ic CD A r,4N 3 2 3 0 Phone #@.011 ." gq �4 foDt7 <br /> L Address 13 yfl / (fD fp , > GI <br /> TCross Street 6rG <br /> Y Owner/Operator qiA I <br /> Ce + SAH Phone jf) O f <br /> C Contractor Name `` <br /> 0 144 +.trt 1ew� imi rj1 c . Phone # <br /> T Contractor Address2 .1 1 C4 Ar�ro�ti 9ys'os CA Lic # / D 0 .5V y y Class <br /> R Insurer ��� �-e Cor1n a "h`�n. �lI (Iramee �irn � Work Comp # 97. 14 ��L , I <br /> A <br /> CICC Technicians Name //�� A / Expiration Date <br /> T ' C�IVQ-a 4. � SC+MCCZ Ex <br /> �tP Z <br /> oICC Installers Name <br /> R Installer's Q C S dvt [ Z Expiration Date ) _ i.{ _ to Z3 <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> Q,e, 87 p;ping sump, 91 leak detector, UDC 11$ eta) y Installed <br /> T 9 Zo les U) /2 <br /> N `TZ q ld /� 41 06 /2 - 2c ) v <br /> K T3 ISGD � ~I2 ~ 211/ <br /> P ❑ Approved LY. Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A i <br /> N Plan Reviewers Name Date I I .Z I t1024 <br /> APPLICANT 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, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TC <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,' <br /> [ApplIcant's Signature <br /> r V Title l.. -� Date / r? -�'Ex � 'z-F Z� <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.(?Q { ee S I Ile In TITLE.c E D PHONE # Loo S 5 wl� 4_ 'folci Y <br /> // n <br /> ADDRESS W. Co ( f7 ,e) �, �� ! Z t cA D , CA 1 53 G <br /> SIGNATURE � — F ��� �7t�A DATE <br /> 2of6 <br />