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SANJOAQUIN Environmental I e <br /> -- COUNTY <br /> J U L o 3 2020 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL HEALTH <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PE "i <br /> MI TYPE BELOW: <br /> PERMIT / SERVICES <br /> ❑ TANK RETROFIT D PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT COLD START/EVR UPGRADE <br /> F EPA Site # L pp0 3 Z3 7f'• O Project Contact & Telephone # C2 v i ) 57+ 3rLJOILJ <br /> � <br /> Facility Name AP. 00 q /v1 8 Z 6 O Z Phone # czo`i 830 �t) j e <br /> L Address y 3 O Jl� e �� r>^ � o /�/Ew �� Qc C>9 q 5.3 `fi <br /> Cross Street c e t/vt L U � •� <br /> TPhone # <br /> Y Owner/Operator �tr ,1ai,,.% � No.� ti~• //&L41K Sy `) 5 } � " 4/ OILj <br /> y <br /> C <br /> Contractor Name ) 1 �,{ oeN4e e • J � e � Sc 4�vlce 31 7+ C . Phone <br /> T Contractor Address • (a ( Cf (cc , CA 9w%o CA Lie # Class <br /> nn _ � � p 2 / VY ' — / 4 <br /> A WorkCom # crInsurer S � e C � .. ��a a�� t ` S � •. <br /> T ICC Technician's Name Expiration Date 7t / 2,f / Z02,0 <br /> T <br /> R ICC Installer' s Name �� � ( sc� � Expiration Date � / S 202 / <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T `TI <br /> N `TZ ' 3 O Ofl O d Uvi ( ecl / 4 <br /> + <br /> K %T.3 0 �' ( 1 200 CD � ( (.� fc r~ & -C <br /> P ❑ Approv A Approved with conditions ❑ Disapproved <br /> A (See Attachment With Conditions) ' � 112,62,0 <br /> N Plan Reviewers Name i f Date <br /> APPLICANT MUST PERFORM ALL WOR ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 9 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "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 /> Applicant's Signature Title C�Z��TLU1 Date L) �0 Zo F)�D <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 IZS/j, Dc TITLE 017M I A PHONE # Z<t:J� S_ i.9 L IV � I <br /> ADDRESS 2� 11 ,5a StE Pam 12 1'/ I / _fit, v1t 10371 <br /> SIGNATURE L' ` DATE.. O <br /> 2of6 <br />