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SA N sJ O A Q V I N Environmental Health Department <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 ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIPJRETROFIT U GOLD STARTtEVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # f�QIq e.. S, 7,0 5--:�j- yo, <br />� <br />Facility Name Aic ( o '1^ P <br />SW 9 3 z 3 O <br />Phone #0-0 5.19 - -4 60 � <br />L <br />Address 3 4/0 1A/ CO /0n <br />T <br />Cross Street Q f C� �, <br />Y <br />OwnerlOperator q Ce+ y!H <br />Phone <br />o <br />Contractor Name t C,4,,A 4,u <br />Phone # <br />T <br />Contractor Address3 t vt n�roc� (A QgS-04' CA Lic # <br />/ D aS'y y y Class <br />Insurer S 4 C CIh. 1 <br />S 1[I. V,fat <br />Work Comp z <br />14 719-Z Ic <br />T <br />ICC Technicians Name d.. 4, <br />C � <br />Expiration Date 44- r Z <br />R[CC <br />R <br />Installers Name C U"Q [ <br />Tank system work area <br />(i.e, 87 P*q sump, 91 leak deWdor, UDC 112, etc.) <br />S"" e4 [ Z- Expiration Date 1-ti-'2.oz.3 <br />Tank Size Chemicals Stored Currently Date UST <br />y Installed <br />T <br />Tr S <br />za k <br />n� -jz-2-12 <br />Aa <br />N <br />t, Iz-2zr-I-- <br />K <br />1-17= I[ e( <br />12k, <br />`)re_.aG <br />VG -12- <br />P <br />❑ Approved <br />❑ Approved with conditions <br />❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name <br />Date <br />'LICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />IQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />c 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 />RKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; "I CERTIFY <br />4T IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />CALIFORNIA' _ <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 + �a ee f _3 I P? TITLE C E C� PHONE# Z0 �' S +� - YO/ y <br />ADDRESS 13 V O W Co �b ✓'1 � CA 1� 1 je d i C/4 q,5 --y <br />SIGNA <br />2of6 <br />—2412-1 <br />