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�7 <br /> ENVIRONMENTAL HEALTH DEPART*' N <br /> SAN JOAQ''IN CO"U <br /> 6EIVED <br /> hITY <br /> 1868 E. Hazelton Ave,, Sto"'Mon, California 95205 <br /> Tefephone;; (209)468-3420 Fax: (209)46$-3433 MAR 0 4 2D16 <br /> APPLICATION FOR MRGROUfVD'STORAGE TANK ENVIRONMENTAL <br /> RETROFIT OR PIPING R-EPAR:PERMIT ���t,��I=t�e.�T�e�rtr <br /> THIS PERMIT EXNiRES 180 DAYS FROM TOE APPRgVAL DATE, iNbICATE PERMIT'TYPF. <br /> D TANK RETROFIT'n PIPING REPAIRAtiROFIT ri UDC REPAIR/RETROFIT 13 COW -VR ARTI-VR UPGRADE <br /> F EPA Site# —.-.. <br /> A Project Contact&Telephone# ~� -- <br /> C :Facility Name _ <br /> Address Phone <br /> t� 222'z <br /> T Cross Street <br /> Y OwnerJOperator —.`...... �•- <br /> U 1 �1 Phone# <br /> d Contractor Name <br /> N Contractor Address <br /> R. CA Lic <br /> Insurer Gass <br /> C iCC Te' Work Camp#. . <br /> c <br /> hnscia <br /> � ns <br /> a <br /> N lir <br /> Q Ex iratio- • <br /> n Da <br /> ]CC Installe <br /> R r5 <br /> - N8m'it; <br /> Expiration date <br /> Tank system work area <br /> 0-c-87 Piprn sump.sl laax detector,Ubc,irz,etc.) Tank Size Che[nl°als Stored Currently Glate IJST <br /> u <br /> insta_INd <br /> N ! 71-1 <br /> -2 <br /> IK —�---- --.. ' <br /> P Approved <br /> L Approved with conditions ( l7isl3ppr°ved <br /> I A (S ltachrnent W€It Cond€tlons) <br /> N <br /> Plan Reviewers Name <br />[ Date <br /> APPLICANT MUST PERF6RI41 AL1,WoRKH IN ACCORDANCE WITH SAN dOAQUIN COUNTY OETDINANCE$ STATE LAWS,ANO RULES AND R6Gt1FA7;ON5 OF SAN <br /> JDAOUIN COUNTY ENVIRONMENTAL HEALTH DEpA13TIJi£NF.OWNER OR LICENSE°AG> <br /> THE'PERFOIiMANCN L3I I LvpRI<FOR WHIGH THIS pE♦ZMIT IS ISSUED,I SHALL NOT EMRLOy/ANY PERSQN RI Si1C�i A•MANNER A5 T09ECOM�St1S{FCTTO. <br /> rVT`8 SIGNATURE CERTIFIES T}!E FOLLOW€NG: ^I CERTIFY TTIAr IN <br /> t�QRK P'S.COMPENSA7i t1+WS.OF CALIFORNIA." C4N7RACTOR'8'}t€RINQ OR SUaCONTRItCTING SI NA7LI E- E,MARTI N THE FoitECOMG: •I JECT€FY <br /> THAT IN THE PERFO E bF 7 THE.W 'RK FOR WHICH THIS Pr=kM€T IS IS, ED,I H LL;Etr1PI-0Y PERSON5.3 B 1 TO 0 BR'S COMPENSATIO€V'f AVUS <br /> OF CALIFORNIA' <br /> APPH is Slg tur„ ZIA <br /> Ti31e <br /> �E8 <br /> BILLING INFORMATiON:. <br /> Indicate the responsible Party to be billed for additional EN€1 steff time expetjded beycnd earl€t a <br /> the party designated below is different than cite permit applicant, erg, property owner, $he par[yemos V owledge kthls <br /> responsibility For the billing by signaturd and data-below, <br /> VA <br /> NAME_ __TITLE. NONE#' 1. .` 1 1 ✓ <br /> ADDF2F5S•,r � , <br /> SI ONATURrz <br />!, DATE <br /> i <br /> EH230038(mvis /3bl12) <br /> f' 2 <br /> i` <br />