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ENVIRONMENTAL HEALTH: D'EPARTMENT <br />SAN JOAQUIN COt NTY <br />--�- <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND. STORAGE TANK RETROFIT OR.PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 980 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW - <br />El TANK RETROFIT ❑ PIPING REPAIRIRETROFIV ❑ UDC REPAIRIRETROFIT ❑ COLD STARTIEVR UPGRADE <br />F EPA Site # Project Contact & Tel # <br />A. 5�-55�co: <br />C Facility: Name Phone # <br />Add <br />y3fS tNa�lerloo ltd Sf oGl�tan R52 <br />:.L <br />Cross Street. . <br />y.;.'. DwnedOperator <br />CContractor.•Name Phone.#' <br />N ContractorAddress CA Lic # Class <br />�: A66�6.- <br />'A 1psurer EX IONer h5itrana Cc work .Comp# WPL50D318-00 ' <br />P , _ - -- <br />T . IGC Technician's Name Expiration Date4. <br />o ICC Installer's Name Iration Date' -7/:y <br />R Lanes? J UA r^' <br />Tank system Work area Pate UST <br />(.e. 87 piping setup, 91 leak detector, we 12, etc.) Tank Size Chemicals Stored Currently Installed <br />T <br />A <br />N <br />K <br />V I. <br />P ❑ Approved !)CApproved with conditions ❑ Disapproved <br />�' -(See Attachment With Conditions) <br />A <br />N : Plan.Reviewers Name 'Date <br />;APPLICANT PERFORM ALLefflK IN ACCORDANCE WITH SAN JOAQUIN-COUNTY ORDINANCES, STATE LAW$,.ANb . LILE$:AND REGULATIONS OF SAN <br />JOALIUIN'COUNTY ENVIRONMEEALTH DEPARTMENT. OWNER ORIICENSED AGENT 5'SIGNATURE CERTIFlES THE;FOCCOWING: 'I CERTIFY THAT.IN <br />-THE:PERFORMANCE OF THE WORK FOR WHICH' THIS. PERMIT 1S ISSUED,'I SHALL'.NOT EMPLOY ANY*PER60N_IN SUChLA MANNER A& TO"BECOME .SUBJECT" <br />ZO'WORKER'S`COMPENSAnDN LAWS ORCALIFORNI,A'..CONTRACTOR'S HIRING.OR SUBGONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY . <br />THATIN THE PERFORMANCE OF THE WORK FOR WHICH THIS�PERMIT Is ISSUED, I,SHALL EMPLOYPERSONS SUBJECTTO.WORKER'S COMPENSATION LAWS <br />OFCAUFORNIA ". ' <br />Apppcarirs Slgnatiire TitleXf 1�iI T l l V V Date <br />BILUNG INFORMATION:.:. <br />Indicate <br />the', responsible party:'to be'billed for additional E•HD sta'ff.finie expended beyond permit payment coverage. per tank of <br />the party 'designated below is sdrfierent than the =permit. applicant e.o. property..owner; .the party must acknowledge this <br />. respo{n'sibilitypfo�rthe biliirig by signature'�:arid datebelow. I�tVlc{a l,kQ i fX J j <br />i�tArvlE� I+el' �dll) rTd.N TITLEc i .. PRONE <br />ADDREs8-L� aA . S CJ <br />. : d .7DilIDnJ <br />sICNA�RE—P1a� a �– <br />. 'DATE.&I'7/h) <br />EH230038 (revised 02/20/09) - <br />1 • <br />I <br />