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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERI* TANK RETROFIT, OR PIPING REPAIR PERMIT <br />T?iZ5 PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. I`-�ICATE PERMIT TYPE BELOW: <br />_TANK RETROFIT )( PIPING REPAIR <br />EPA S_TE PCAL <br />A L/�0000 �SCr 3 �J I PROJECT CONTACT & TELEPHONE # �-E.'r O:VA,( rlle6r, r/0 -p4 S' gs00 <br />FAC:LITY NAME QU(IC STOP l y�'i PH_ q Z 09 - I S - Z - uQ% ii <br />~ ADDRESS �Z}•i.- u%EST- LA,k4rL $-r OC1(.T0-( CA 9 S -C\ 209 <br />r: ROSS STREET A VK V%F n- -ro %09 <br />OWNER, OPERATOR I PHC - q <br />Q U IIL STOP VK A fLIC&A—S , �V'4c S/o - (o S - r so 0 <br />CONTRACTOR NAME 1-14 C • PHCh_ q t/4 <br />N' ir.Oh : RACTOR ADDRESS c CA LIC # / } Z 3 g CLASS j� 1 <br />Q 0, Q lC / 0 s r W- S Arum C A, 10 !� Fi <br />:Ns RRER STAr'r� Com&P /n(S- �U WC %.COMP.q /`t2�-0o <br />OTHER INFORMATION C o -r A-cx = M i C 14 fit- A L're P4 <br />K <br />PHC\-. <br />—1��11��►�I��ii��l�l������������1 <br />T ID q TANK SIZE CHEMICALS STORED CURRENT'! /PREVIOUS L-! <br />APP' -:CANT'S S:GNATURE: <br />IC41 A" E- WP%Lr. 0 V <br />1 BILLINO INb'ORMATIOIT: <br />ISA.??ROVED <br />DATE <br />DATE UST 'NSTAL'ED <br />I <br />•a, AND RULES AND REGULATIONS DF <br />FOLLOWING: 'I CERTIFY THAT :N <br />ON :N SUCH A Yn`INER AS TO BECOME . <br />TING SIGNATURE CERTIFIES THE FOLLOWING,; <br />EMP:OY PERSONS SUBJECT TO WORKER'S <br />TITLE (�h &t>R-+rT DATE 0 L 2 G 0 I <br />indicato the respeneible party to be billed for addit:iortAl PHS -Z= etaef time expended beyond <br />permit payment boverage per tank, if the party designated bolow is diLterant than the permit <br />applicant, e,g, property owner, he party mvat acknowledge thio responsibility for the billing <br />by signatureand date below. <br />Name /�%/�� /CAR�!i LJ 7' address S�7.L;✓��: y�•rt hone nwnbar -y114 -Zzff' <br />S i grI a to r A-•--��� � „�G��--:�_ (;� ,� ; (c � �r,p /4'iJ-z /c'u*'�r ,l �J r . <br />EH 23-0038 <br />1 <br />39- ► I /O�000 <br />I REC. <br />T <br />I 39- Z I IO�o00 <br />Atyi <br />A <br />39- Z I <br />8. Coe <br />I Pl\e"w. <br />39- 1 <br />N <br />39- 1 <br />I <br />K <br />39- 1 <br />? I APPROVED <br />APPROVED WITH CONDITION(S) <br />A I <br />(SEE ATTACHMENT <br />WITH CONDITION <br />N I P'L.A-17 REVIEWERS NAME <br />APPL:CANC MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUI <br />CO O INAA <br />SAN .;CAQUIN 'C'OUNT'Y PUBLIC HEALTH SERVICES. <br />OWNER OR LICENSED <br />GENT` IGx�T <br />'HE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, <br />OT EM <br />SUB.:ECT TO 'WORKER'S COMPENSATION LAWS OF CALIFORNIA." C\COQNrt�¢`.q <br />HIRI F <br />-=ERT:FY THAT :N THE PERFORMANCE OF THE <br />WORK FOR WHIC11 T3i�I� <br />PE T IS UE <br />_OMPENSA7:ON LAWS OF CALIFORNIA.' / <br />VJJJ''' <br />APP' -:CANT'S S:GNATURE: <br />IC41 A" E- WP%Lr. 0 V <br />1 BILLINO INb'ORMATIOIT: <br />ISA.??ROVED <br />DATE <br />DATE UST 'NSTAL'ED <br />I <br />•a, AND RULES AND REGULATIONS DF <br />FOLLOWING: 'I CERTIFY THAT :N <br />ON :N SUCH A Yn`INER AS TO BECOME . <br />TING SIGNATURE CERTIFIES THE FOLLOWING,; <br />EMP:OY PERSONS SUBJECT TO WORKER'S <br />TITLE (�h &t>R-+rT DATE 0 L 2 G 0 I <br />indicato the respeneible party to be billed for addit:iortAl PHS -Z= etaef time expended beyond <br />permit payment boverage per tank, if the party designated bolow is diLterant than the permit <br />applicant, e,g, property owner, he party mvat acknowledge thio responsibility for the billing <br />by signatureand date below. <br />Name /�%/�� /CAR�!i LJ 7' address S�7.L;✓��: y�•rt hone nwnbar -y114 -Zzff' <br />S i grI a to r A-•--��� � „�G��--:�_ (;� ,� ; (c � �r,p /4'iJ-z /c'u*'�r ,l �J r . <br />EH 23-0038 <br />1 <br />