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E:.NVWONMENIA(_ HEALTH DEPARTMENT <br />SAN JOAOUIN COUNTY <br />600 1 a..1 11'I,tin Street, Slocklim, Cal (w(ji:I 9521)2 <br />11•Il•1111-n1c. ( 209) 46S 3420 1 a%: (2111) 4 4) 8 ,i13.t <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />f 111> h'tHMl l l WWI " 1811 OA Y'. 1 14, 1M r1 -If .AI'f 9n iv,1j 10 INf 114 A If 1'l I'All I l , l l 111 i W <br />I I TANK RETROFIT /PIPING REPAIR/RETROFIT , UDC REPAIR/RETROFIf /COLDS TAR TIEVR UPGRADE <br />E <br />FIA Site tf I ,•,I,• t I •I,•tif1c1n1• #1111 Ial;f•N>l�,,,� �i�_.2 I-i�oc <br />F aclhty Narne`[ �ES>Jrt�U %8 1 53 I I ,nc- #—.:p <br />I <br />Address,Z� 8 Wes iC 'Cti.E! (Ad % L nct LCr !FZ <br />t Cross Street Lauj E m SPtC <br />y Owner/Operator 1-1 <br />ESpqV QEFluW,in � t�A,;t,cE-r�tN� ��� Pnnnt• a s.rlr`, <br />Contractor Name � 1.� F'hunr k <br />ra -- - _i t '-r6r A�)GE `lam 1- S�iS - 5S <br />1 Contractor Address t2zq QF in p��1- �r'A i-itWAZI 1 (.A l Ir. a�l Z ��r Clays $ Aj C-1�1 +A Z <br />A Insurer' S T-ek rW Work COnlp tI Q 07_ S-71 1 <br />I ICG Technician's Name • Expiration pate <br />c. - '-- <br />I, ICC Installer's Name Expiration Date <br />Tank system work are,I Date US I <br />-- - (1a 87 piping sump. 911eekde11c1u1.(1oc 1/' �--11.1 I<lr,h S1_ Chemicals Stored Currently Installed <br />- - - <br />t-Y.-+4c-tE lE trr_►Nb��,1 ,,� SY'E -- - ' 1 _.N*Aj GAIL. Arrt� - <br />A _ —.� <br />'��'~ E � �- NIE t.J vt Ss � t s'�.c -t . IJc�G ?-�- n E �K�r✓,'t� c�."�• - R�o: � SoGTlallPl7t,E <br />V R.5�.�N 'co I10 Vfq;,j ow v( Govp C--IVrt.4r-. <br />I I Apfunv�a we�1 with o:; I,itr.nl. Disapproved <br />A fit With Conditions) <br />N Plan Reviewers Nam <br />Datr. I <br />/APPLICANT MUST PERFORM ALL WORK IN AGCOROggy�iiCE WI IH SAN JOf ,(i!N COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAOUIN COUNTY, ENVIRONMENTAL HEALTH H . A TMEN I OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWIING "t CERTIFY THAT IN <br />TO PERFORMANCE N THE WORK FOR NJFIICH THIS PERMI T IS ISSUED, I SHAT L NOT EMPLOY ANY PERSON IN SUCH A MANNER AS To BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OI' CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK r r, WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA " `` 1 / j <br />Applicant's Signature _- _ — - Titin vr% VA-^- - - `�f , 2 /�jIk/ <br />Or BILLING INFORMATION: <br />Indicate the responsibl party to be billet! for additioital EHO staff time expended beyond permit payment coverage per <br />tank. If the party desi7nated Wow is different thall the permit applicant, e.g. property owner, the party roust ack.nuwledge <br />this responsibility for the billing by signature and date below. <br />NAME Ei'.� 3 �D6`'G` <br />ib1 TITLE__�'�IJ' <br />A?7RFSS- <br />E75 Slt�t+f __ fr1j #'L'>D(%1t).r c4ijk3p 7 � c4P*" 139- 7 <br />SIGNATURE _ _ tol-7 <br />— --,-- --- - BATE -- <br />2 <br />EF1230038 (revised 07/22/10) <br />2 <br />