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" ,NVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK RETROFIT, OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TY--T- BELOW: LlG� <br /> _TANK RETROFIT PIPING REPAIR /�" co�� <br /> EPA SITE # PROJECT CONTACT 6 TELEPHONE q J-7132 atyb <br /> A ' FACILITY NAME MIEN 1CA P PHONE # _6GQC) y(p-`b <br /> r l i t _ A � I L ` �•� <br /> IADDRESS } /�\ �/`�'+ L�-•A-IJ V L� L7 6A • <br /> II CROSS STREET <br /> T I OWNER/OPERATOR I PHONE # <br /> Y I Y C �Dl I z� - 333-(o$Uv u <br /> C CONTRACTOR NAME '(� -re-- PHONE # ZOc_ ^(p(- &'5/ <br /> _� 1 A <br /> Ti CONTRACTOR ADDRESS✓2SZ,` �1! wA+A DEQ qe, CA LZC q /&DO -•�/_ I CLAS`s 3,C-ID, k+Z�r <br /> R I INSURER ,',`,` I- � ✓rvt "lGO ,v P& <br /> 1� I WORIKt.�COMP.q�lA'��(i/�i'✓WY Zz DD 174 -1-1 <br /> A <br /> C I OTHER INFORMATION I I <br /> T <br /> 0 I I PHONE # <br /> R <br /> PHONE # <br /> TANK <br /> TANK ZD # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY '-'= UST INSTALLED <br /> 39- 3r74O I -7-!,000 <br /> ODb G,A - - I U�NLGA-t�Fii� GA-�o�lt�l� I S�Pr. M6 <br /> T 139- I z .000 4A-LI Dt 5 �-- I �—I <br /> A 139- 353 1 5, 0 I 1 s I s I <br /> N ( 39- I -2-',0 1)r) At— - I W TE >tL_ I 5L-Pr.* 1,18ja I <br /> K j 39- I I I I <br /> i <br /> 39- <br /> 39- <br /> L <br /> 9-39-L j APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A I (SE AlTT/a`CHM�ENT WITH CONDITIONS) / c <br /> N I PLAN REVIEWERS NAME �y / /`"'F--1� �V'T DATE ��/II g <br /> �IIIIIIIIIIIIIIIIIII111111111111111111111111 Iilli I I Ijljilliljjljlljilljlllljlllljllljijllljllllljjillljllllllllllljjlijlll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND ?=GULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "- 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 iS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERT--=--ES THE FOLLOWING:I <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS'ISSUED, I SHALL EMPLOY PERSONS SUBj= TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." I <br /> �1,r� tA'u�t ns►s <br /> APPLICANT'S SIGNATURE: TITLE j"�It'� l�� :,.c Iz- O <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond <br /> permit payment coverage per tank. If the party designated below is different than the permit <br /> applicant, e.g. property owner, the party must acknowledge this responsibility for the billing <br /> by signature and date below. # <br /> Name C� L s addressfo aaY 360(R _ LAwone�number<T 33 3 -(vMD . Otv <br /> Signature <br /> EH 23-0038 <br /> 1 <br />