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KJOAQUIN VED <br /> EiEX!;!nI Qealth Department <br /> SAPR 2 0 2018 <br /> —COUNTY­ <br /> APPLICATION FOR UNDERGROUND STORAG&t#WRRNMENTAL <br /> RETROFIT'OR PIPING REPAIR PE TIS DEPARTMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT"?I-BELOW <br /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT a COLD START/EVR UPGRADE <br /> F EPA Site# Protect Contact&Telephone# VS`7111 <br /> A one <br /> C FaclgtyName C4r,'yr10A1 Ph <br /> RtV4eAe__9 <br /> L Address <br /> Cross street <br /> T <br /> Y owner/Operator 00 Phone# <br /> 0A Phone# eve <br /> Contractor Name a'.1 <br /> .)L <br /> N Con ✓ Class A /3 <br /> tractor Address <br /> T CA Lie# 300J�� D Pao <br /> we*Comp#/a 00 OtD <br /> A <br /> lnsurear 4k 1,` WNW <br /> ICC Technan's Name 11� " <br /> T Technician's 7 ez Expiration Date <br /> 0 <br /> ICC Installer's Name Expiration Date <br /> R na <br /> Tank system work area Tank Size Chemicals Stored Currently Date LIST <br /> 87 WM wx*91 ImA daWW.UDC UZ dr-) Installed <br /> T <br /> A <br /> N <br /> P 0 Approved Approved with conditions El Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Date <br /> IX) <br /> Plan Reviewers NameL_ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULOONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.OVMER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PFRFQRMANCE OF THE WORK FOR VIA-11CH THIS PERMIT is ISSUED,I aKAn NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> MRKER�S COMPENSATION LAWS OF CALIFORNW CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWIft I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORkER'S COMPENSATION LAWS <br /> Of CALIFORNIA.' <br /> "pliods S ure TIIe Datm zz' <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per <br /> tank. If the party designated below Is different than the permit applicant, e.g. property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> NAME� TITLE PHONE# <br /> $_0 <br /> ADDRESS 'W.9 4 LO <br /> SIGNATURE ,_.,!:�:��� 141- P <br /> 2 Of 8 <br />