Laserfiche WebLink
SANJ OA III Environmental Health Department <br /> OUN Y <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 160 DAYS fROM THE APPROVAL GATE. INDICATE PERMFT7YPE R4a0w. <br /> O TANiK RETROFIT a PIPING REPAIRIRETROFIT O UDC REPAIMETRORT 0 COLD STARTIIEVR UPORADE <br /> IF EPA Site# Project Contact✓S~Telephone# �.- <br /> A <br /> C Facility Name R-M-0 phone# <br /> Addreal)1� p " 1 k 1 2z <br /> Cross Street - <br /> Y bwnerlOp@mtor r% 1Y1 Phone# <br /> Conuack w Name f� qyon �' Phone t L <br /> T Conkractai Address GNX'-V\Y1 CA Lic# Cfass lal <br /> A Insurer t Work Comp A7 ICC Technician's Name Expiration Date <br /> it ICC tnstal.ler's Name Expiration Raise <br /> Tank system work area Tank&zD Chemicals Stored Currently Date UST <br /> V pON Knp Vi Ideka.intw.UnC W,Mr.) Installed <br /> T <br /> A - <br /> N <br /> K <br /> �9-AppFoved Witt)conditions ❑ Disappmved <br /> U ($ee Atiachmenl With Conditions) <br /> A <br /> N plan Reviewer N" r C+ • [� ems+ Date J 0 O Z <br /> PUCANT WJSY PERFORM ALL WORK IN ACCOISDANGE WITH SrAN JOAOUIN COUNTY ORDINANCE STATE LAWS,AND RULES AND REGILLA710HS OF SAN <br /> OkWIIR COUNTY,ENVIROMMENTAt HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S ELGHRtUALE CERTIFIES THE FOLLOVING. 'I CERTIFY THAT IN <br /> HE PERFORMANCE OF THE 4tiK K FOR V"CFr 7HIS PERM IS ISSUEC: I SHALL NOT EMPLOY ANY PERSON 30 Bt.ICI{A MANNER AS TO BECOME SUBJECT TO <br /> I±;KER'$COMFFN$ATION tAV4 OF 0AIjF0RNI&- 00NMq*MR'5 HIRIN43 OR SUBCONT3RACTEN6 SlGNA7URE CERTIFIES THE F01-1,06MINC! 7 CER77FY <br /> T IN TH E PERFOR MIANCE OF THE WORK FOR WHLCH THIS PERMIT IS ISSUE D,I SHALL WLG .PER"Z SUBJECT TO W+ Kr&R'S tOMPENSATI(M LAWS <br /> OF CALIFORNIA" —�i+ <br /> 4 kurs 8"CL 4 JLA�_Titwos 4 own <br /> I3ILL.ING INFORMATION- <br /> Indicale the responsible party to be billed for addktlonal EHD staff time expended beyond permit pRIyMenl coverage par <br /> tan - If the party designated below Is dlfferenl than the permit appflcant, e.g, property owner. the party must <br /> acknowtedge this responslbIlKy for Hie billing by si netLire and date be <br /> NAME -)(WIZ* x TITLE -1!VCN-CA,!V 41� PHONr; <br /> ADQR4:-9S � (3�1nn 1 , la>� `o s CA -Reokk 1 <br /> SIGNATURE -_ --- _DATE. <br /> 3af� <br />