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Nov 20 14 02:03p Ell-tfb Iv Contraotors Ino 209461 42 p. 5 <br /> N,UI' 4 MENTAL HEALTH DEPARTMENT <br /> _ ,....._. . _,.: ..::SAN--JOAQUI•N COUNTY <br /> .600:-EaSt•Main Street,'StOd ton, Caftfomia 95202 <br /> Telephone:(209),468-3420 Fax:(209)468-3433 <br /> APPL•ICATION-FOR UNDERGROUND SiTORAGE TANK <br /> RETR-6 OR-•PIPING RE0AIR`PFR.m1T <br /> THIS�z+U I7CPIMS-100 DAYS FRW THE APPROVAL Dart~.JiM&Te p0-U PC OELOw! <br /> D TANK'RETROFrr`0 PIPING REPAIRIRETROFr.r D UDC REPAIRIREMOF T 17 COLD STARTIEVR UPGRADE <br /> EJF [ky-Naftibl, <br /> $Ire,# - <br /> A ProjemcO6ta .B TerephOne# ' I-y 'i l'1�I r <br /> C rPrlone# <•� ssT $ftd <br /> Y '„ 1 <br /> c o ' MP #l <br /> hone <br /> T Ctll7hS(dOr•/{dd(ess -...c. lY 7 r••; <br /> R CA tic*(�L�Y'J1(e <br /> FRIG' <br /> A . Insurer �; ;.: T P i t fiaC�".. yvatk c1 ' <br /> c CepI �J.. I. <br /> 'ICc :�. <br /> T ICC Technldan's Name Expiratkr,Date <br /> R •lCx InStaliel's•Name• <br /> Expiration Date <br /> 0 e s�p��� ucyz.,%) Tank S¢m Chemicals Stored Cummdy Date UST <br /> Installed <br /> T <br /> A <br /> K <br /> p r' �m <br /> L. LJ with conditions ❑ Disapproved <br /> A �S Attf <br /> N Wan Revie ms Name ( ? <br /> Date <br /> --••--:. . •=ter._... . .. LN <br /> rwrfr-aWST-wc.REORN.AL::� .•. AccaXMQU ;,,u+iaApvuu MANCET,srwrL u --- <br /> �l.courrrY,elwlRaNn�cxru HeAI.Te+OEPA OWNER OR LIC ® s1[iNATlMttr CERTIFI[rS 7}IE F R u 7 T <br /> E�8R5y jN <br /> VENSA TK-IM WORK'FgR WHkai 73115'I' rIT!S ISSUED.! NPLOY AMrYAERSQri(N.SUCH A M4Wl1ER AS Td B .SUBJECT YQ <br /> 4. ft -.-^ QK.CJIt]lt NCA''L�4MRAC .HIRING SUOUMTRACTINe.SK�NATUPO CER'ryFt�S THE,FSOLLOW!Wx 9 Camry <br /> __.RC IFORNIA CSE Of;TF�NIORK FOR VYHICH fHiS P urr.l6.tSEt►CD.I...�I�yt�,GIPLDY PCKSONS;.SUBJEW TO _....CORC4VASAMON'LAM .. <br /> TlC3N-tdtYYS; <br /> - Y M TNE•PFJiF <br /> aaumnc's „tee•��u i �!t.:'x' Two r, i;, .,�,�,�• , � oar ;�' <br /> .NORMAT.ION_ <br /> �ndfcate.the�.rr3sporAsiNe <br /> rl�F <br /> _._ low tabs-dllled for addglertel FID;staf�time e:tpended-.... d;Permk pay�rlent r laltk. It <br /> tfte':AaitY_des belotiv_is=' t coverege.pa <br /> �t'ahaq_ttrd" _ _ <br /> _ PWh . e•9. property Owner. tW party mm--t _. <br /> P_ bllk ortlie bUiujg.hy_gi e_a�d date below. �e <br /> Elill <br /> �r �( <br /> SIGNATURE t�1t'Yy� �:�L \Z .... t)ATE t r��i w <br /> Ftp.30d'dg(ievlsed:0911M1� . <br /> --....__. . ... ....._.__. ®._...------_ ..... .........._�._._._.. _........ - —...._. REGENEu <br /> 2 <br /> NOV 2 0 2014 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />