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r ko q <br /> SAN,J O A Q N I N Environmental Health Department <br /> COUNTY DECEIVED <br /> APPLICATION FOR UNDERGROUND STORAGE TANK JAN 0 8 2018 <br /> RETROFIT OR PIPING REPAIR PERMIT 1J��,��tir� ppn/-�� Inn u <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE&EL13VIRONMENTAL HEALTH <br /> ❑TANK RETROFIT ❑PIPING REPAIR/RETROFIT XUDC REPAIR/RETROFIT ❑COLD START/ffpffI+yRi�DN <br /> F EPA Site# Project Contact&Telephone# �R>I� 14A6� 11tfI�I7�'—89 Z& <br /> A <br /> C Facility Name fi N Phone# <br /> � <br /> Address S15- 890, 1rWfll' 7MAcV CA 9557 <br /> I Cross Street <br /> T <br /> Y Owner/Operator EFR!lVuWLN Phone# <br /> C Contractor Name 4AW-o -<CROcE� Phone# 77o—�f 1 _ g <br /> N <br /> T Contractor Address -7p 3q ,6A CA Lic# q B IZg Class g ¢}E} <br /> R Insurer <br /> A Eli+cam _rN'r�-F'f1°TI� SNS. Co. Work.Comp#4J'NJ(,C'J f}Z6y1Z.8 Zp 1 <br /> T ICC Technician's Name 6RR1t AoLL4S 4 pz&$ Expiration Date y z-VZ019 <br /> ' <br /> ICC Installers Name <br /> R :3tgej j4OLuS •kik 105-1867— Expiration Date q)I Zoe <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e,87 piping Sump,91 leak detector,UDC 112,etc.) Installed <br /> T Mz�rn1`s ,mQ5 b+ z <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions El Disapproved <br /> L t <br /> See Attachment With Conditions) <br /> A11N Plan Reviewers Name Date 1 /24 <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 AGENT'S 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMA E OF THE WOR OR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." �- <br /> Applicant's Signature Title Date <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. �J//Pf�7 � <br /> NAME b�RRti Iy ' iL0k__ —TITLE &_fL PHONE# 7 `�1Q 7—l-Q 1 Z <br /> ADDRESS 5470 �T4T� Ft-� �1,�1/l�i Z1��4�1� `'1) 39 <br /> SIGNATURE DATE 18 <br /> 2of6 <br />