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(� EnvironmentalRIE <br />+jar t ' <br />' I) <br />SAN JOAQUIN <br />COU N 'T Y ------- <br />0C i 0 to L017 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT ENVIRO�NV"!T^'. urALTH <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: ?� r—" k- <br />0 <br />❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE CcIAver5cun <br />F <br />EPA Site # <br />Project Contact & Telephone # tCCP011r,. 51-12-74,Z5'111, <br />A <br />D <br />Facility Name "'Pnnhone <br /># <br />L <br />Address j �3 a vl �33 <br />TCross <br />Street <br />Y <br />Owner/Operator}- <br />Phone # jfl 1 . 23 - 7a 2 <br />C <br />Contractor Name Air\, ecI'(G — <br />Phone # •" -76 L _<?t Z <br />N <br />T <br />Contractor Address 0 G - iu 7 QQ609 CALic# QSZLf3 Class a.Z <br />A <br />Insurer �� l0 CO3<,CA0\(1 <br />Work Comp # Q0 0 35_d <br />T <br />ICC Technician's Name p A <br />Expiration Date _ Zq -1 <br />R <br />ICC Installer's Name (T� [ice <br />Expiration Date -j <br />- jg <br />Tank system work area <br />(i.e, 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />' q lC <br />T <br />To CC✓t v[ r e <br />A <br />N <br />K <br />P <br />❑ Approved 9 Approved with conditions ❑ Disapproved <br />L <br />(See Attachment With Conditions) <br />A <br />N <br />Plan Reviewers Name U _ Date � 7/ �6 R <br />APPLICANT MUST PERFORM ALL WORK IN 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: "I 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 />P <br />Applicant's Signature / - !r Title I r �S (d r yyL Date 25' 17 <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 />po <br />acknowledge this responsibility for the billing by signature and date below. ! l <br />NAME ,IOJ't e- IC",%q l / C(W1, !j6g(��W`ITLE �S�SIC�tw� PHONE# 5b,�C'74 Z 'N67Z_ <br />ADDRESS Y 0 <br />SIGNA <br />2 of 6 <br />TE q -04-t <br />