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A4 +O Q I EINVUBJUnWifal F oaltl) 40partMent <br /> - -COUN1 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> 7"FgPER"IT EXFIF;ES190iDAYSF ROM THE APPR(rVA1.O47E, INDICATE PER10IT TYPE HELOYf <br /> TANK RETROFIT I PPIPJNG REPAIRIRETROFIT D UDC ROPAIWAVR8FIT r i COLO STARTIEVR UPGRADE <br /> F EPA Sao " Project Contact&Telephone# <br /> Facility Name Ptlone# Dr <br /> I Address <br /> L UrX CA <br /> I trross Street <br /> y OwnerfOperator LAMPhone 0 — c <br /> antractor Name C Ca ivyPhone# - <br /> T Contractor Address : D r CA tic# ' ]3L41 Class y / <br /> RInsurer Work Camp# Iq 0 o <br /> T [CC Technician's Name Expiralion Date <br /> � ICC Installer's Nanne LALb Expiration Gate I off. cr-w <br /> Tank systetn work area Date UST <br /> (I-b.$7 POrgSur%,99 JeY[deledfx.unc+rx.M=F Yank;}ita CtlerrlJcals Stored currently Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Atlachment With Candilions) <br /> A <br /> Plan Reviewers Name -- Date - 3 12 D <br /> PLFCAIYT MUST PERFORM ALL.V�CRK IN ACCORDANCE WTH qAN JOAQUIN COUNTY ORDINAJRCES,STATE LAM,AND RU1ES AND REGULATIONS OF SAN <br /> OAOUIN C NTY, ENORON MENTAL flEALTIA DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOW NG: 9 CERTIFY THAT IN <br /> THE PERFORMANCE OF TKE MRK FOR WHICH THIS PER MIT i$I55 UED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNQR AS TO BECOM E$u&.ECT TO <br /> F Ft'S COIAPE46AMN LAM OF CALIFOkNLk' CONTRACTOR'S HIRING OR 8uacoNrRACnNG SIGNATURE CERTIFIE$ THE FOLLOVONG: 'I CERTIFY <br /> THAT IN THE PERFOR kMCE OF THE U'.K}RK FOR WHICH THIS PERMIT IS ISSUED,I SHALL,EMPLOY PERSONS SUBJECT TO VVDRKER'S COMPENSAT10M LAWS <br /> =nj'# <br /> UFORNIA.' <br /> S pM1i4Uf4 � f T,0* iD.11 t 4Y S i <br /> BILLING IWORMATION: <br /> Indicate the responsible party to be billed far additional EHD staff lime expended beyond permit payment coverage per <br /> tank If the party designated WOW Js different than the permit applicant, e.g. property owner, the party must <br /> acknovdadge this rBsponsiGitity for the billing by signature and date below. + + r <br /> NAMC .) ?-:gA.e �1 Yli_ TITLE 04 C '- PHO NE 0. <br /> (A ccl <br /> SIGNA7URC DATIr CI r (P lam <br /> 931 fi <br />