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,ALN JOAQUIN COUNTY <br />ENVIRONMENTAL, HEALTH DEPARTMENT. <br />ENT <br />304 E WEBER AVE° 3M FLOOR.. <br />STOO TCA CA 85202 <br />APPLICATION FOR UNDERGROUND TANK RETROFIT. OR PIPING REPAIR PERMIT <br />THIS PERMIT.EXPIRE$ 80 DAYS FROM THE APPROVAL DATE, DO NOT PYRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE SELOW: <br />__TANK RETROFIT ;PIPING R3PAIR/RETROFIT _UNOER DISPENSER CONTAINMENT REPAIR/RETROPIT <br />+----__ __ ..^---=----------------- --^�.----------- w-_..---------- + <br />1 1•EPA BYTE # 1 PROJECT CCNTACT A TELEPRONE # t <br />! +----------=-----------:. ------_-.^...--^--------- ^.... ------------..^--- _ ._.. ----'--1 <br />} F ; FACILTTY.NAME 'a_,�,' = —+ <br />A �. _ /�t�J� cam. vY! l .� _ 1 PR i -. $ — _�----------- <br />iC <br />.0 ADAtze66------`Lr .�.� v1 a-- _�[._-----_^ __ -- --- _-__ <br />1. L = CROSS 6TREETT Fl 011-p-. -t- - ------------------------------ <br />Iz ------------=-----=-------- ------ ------------------------' <br />--------------- - p �„ �f <br />T I. OW[Y�B/bPERATOR cP_Q ft i PHOL>8 #�R ®- 0 V G� j Q ! <br />C : ---C01------- IQAMIi `":�L Y 5 � �"�`A{Y ""' ". X51 `�S �it S/� e� ! 105194I PRONS <br />----------------------- <br />---- # ��. - ------ qK�_�3 `1'� ' <br />iN +CONTRACTOR ADDRESS [`\ iQa,�rA,,j,,�, p_ _J0.i.l.(�,�yQ&k �1 � lo���q«•�-CA iIC #__ --N-- CLAS6PJ�IQ�,'1 D:1'' s/..Q�� {�'t1G <br />A 1_;NSUIM -� _ _ "Mi`y�• ill �al SEGS 47r Kz ----- _I [AORR_CBMP�Q'^- ' <br />t {^ _ <br />C i OTHER INFORMATION w t ' <br />iT+----------------------------------------------------------------- ----- ..-.....-----____.....^------ ---___----------3 <br />O i 1 PHONE # t <br />' R w----- -"---------------- ^------------------- ---------- ------• --------__—.........w ------ "-_ —------ -^-----.,........... <br />1 <br />PRONE # <br />t <br />i <br />t 1 TAN1G ID # i TAK& SIZE : CHEMICALS STORWrO8 <br />CMMY/PREVIOOELY 1 DATE UST INSTALL= I <br />. 3y .'A ! { 1 <br />T i 39- ! ! <br />i 2i30. <br />-t II ;f:•.f'.'r1, Ii111{It1{�� i. :;:...1. }1' t{1}11 1,1Ill: I.i. Ill {i 11i1t1111ltilll:.1I}t11 „ 11.}!. I::;l.. 11i�1.If1,1;s1 <br />Bas 1 <br />e L 1 _� APaROVBD APPROVED WITS C0NDYT2CU(S) DISAPPROVED <br />1. A i . ' (BEE ATTAC11ME T MITA C=ITION6) <br />4t p 0 Z. } <br />I' 19 PLAN FSVIEPF$1i5 ,NAMt;_ 1 . N DATE i t?' �.®"0 'T <br />t{t11{{ii'1}1.{1:: Y.t11ILI:1,1'11''iIII!:;1f':;f9f11 1"ttint..}{ I}{}::1;:1111}tl}t11}}Iltt{11:It1{11}iT ii:lt}}ilIli <br />!, t <br />i "MUCANT MUST. PERFORM ALL WORK IN ACCORDANCE NITA QAN TOAMIN COONIY ORDZUMC'66, STATE LAWS, AND RULES AND REGOLATIONs OF t <br />SAN JOAQVIN Y, :RNVIR STN DEPARTMENT. OWNER OR LXCB499D AGENT'S SIGNAT9RE CERTIFIES THIS FOLLOWING: •I CERTIFY ° <br />1 TMA2 IN TRZ PERFORMANCE OF TEE W= FOR WHICH TBI: YY Is ISSUED, I SBALL NOT EMPLOY ANY PER%a4 IN SUCH A'MNMER A; TO 1 <br />1 BECOME -'OBJECT TO WORKER'S COMPENSATION LAMS OF CALIFORNIA..• CONITACTORIS HIRING OR SUBCONTRACTING SIGNATORE . CxmTIF2BE Tig <br />t <br />' sOLI.bNYNG: "%'CERTIFY THAT 179 THE P&RFORMANCE OF T= WORK FOR WHICH TRIS PERMIT xs 265i78D, I SflAI.L EMPLOY PERSONS SIIBJECT TO ' <br />1 WORRER'S COMPENSATION LANE OP =TPORNIA.• I <br />t t <br />!. InnT.TrimmYf( nT(111nI1Cm111i MW <br />BILLING INFORMATION: <br />Indicate the responsible party t6 be billed for additional EHD staff time expended beyond permlt payment <br />coverage per flank. If the party designated below is different than the permit 'applicant, e.g. property <br />owner, the party must acknowledge this responsibility for the billing by signature and date below. <br />rt <br />Name &TrUC 2 �j addre'ss bt®( Digo AVIC .��_e'Ph ne# <br />Signature <br />EH230038 <br />{revised 1/31/0) <br />