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S A ,- JOAQUIN <br /> Environmental Health Department <br /> COUNTY <br /> APPLI ATION FOR UNDER ROUND STO RAG E TAN K <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> TMIJ3 PERMIT EXPJR E S I Oo DAYS FROM THE APPROVAL DATE. INDFC 1TE FERMFT 1 YPE KLOW <br /> ❑TANK RETROFIT a PIPING RE PA RIRETROFIT o UDC REPAIRMETROFIT ❑COLD STARTrEVR UPGRADE <br /> F EPA Sito A PrageOt Comw$Talephorm# � <br /> CFacility Name ' Phone l <br /> L Address I .. 1 <br /> t crass Street ` <br /> T <br /> Y OwnerlGperator Phone 9 ,—,t .. <br /> a <br /> Contmcto r Nam a I?hone at <br /> T Contractor Address % CA Llo# Class Be� <br /> R Inswer - Work fiorrlp <br /> T I C Technician's Name *, ira#iorl Date <br /> ICC InBtallees Name I -- Expiration Date <br /> Tea syslem work area Tank Size Chemicals Stored Currently Date UST <br /> �Le.Sir PON eV,$l Ie"atkow.uw-ill,ft) lnStalled <br /> T c <br /> ,&— _l <br /> N -- <br /> K <br /> p Approved with aondilicns ❑ Disapproved <br /> L (See Attachment Wilh Conditions) <br /> A <br /> N Plen Reviewers NVarne� { .42e&I � Date <br /> J'UCANT MUST PERFORM ALL VMRK IN ACCORDANCE VKIH SAt#JOAQUIN GOUNrY ORDIRANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> OApWN COLNTY,ENVIRONMENTAL HEALTH DEPARTMENT-OY4NER OR LICENSED AGENT'S 811- }ATUAS CERTIFIE$TAS FOLLMMNQ 1 CERTIFY THAT rN <br /> HI:PERFORMANCE OF TKE VVORK I:OR WHICH M$PExWr I$I..a'jEV,I SI+ALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A$TO BECOME$UWEGTTO <br /> WORKERLS COMPENSATION LAWS OF CALIFORNIA' COHrRACTOWS MIRING OR SUBCOWFRAGTING SIGHATLIRE OERTiFIn TIME FOLLOWING: 'I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE YJORK FOR VYHFCH THIS PERMIT 13 ISSUED,I SMALL EMPLOY PE=R$ON.S$L1 WE-CT To WORKER'S COMPEHSATIC&U11A+3 <br /> kalft$Ignf0.Qa Tide c�.0 y_, 4V pub � 7'L� <br /> BILLING INFORMATION; <br /> I ndicale the respo risible party to be bred for additional EH D staff time expended beyond permit payment coverage par <br /> tangs. If pia parly designated below is different than the permit applicant, a-g, property ovf r, the party must <br /> aokno a go this rimpor bIl ity for the bi Iling by signature and date be w. <br /> % � 1 TITLE PHONE* k-jV)—2A;�_�D <br /> S3GNATURE DATE P L <br /> 3of5 <br />