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,T 7 li ! l� I <br /> SAN JOAQUIN Environmental Health Dep" ntE: D <br /> C 0 U <br /> 1 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT laE ; l 'AtZd ;ttill N1 , <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE . INDICATE PERMIT TYPE BELOW: <br /> TANK RETROFIT a PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT : : COLD START/EVR UPGRADE <br /> F EPA Site # G p. L 00 0 16 2 3p Project Contact & Telephone # Ac'i 1 G k ,( 5i0) 0114 ' — 12. 1 5 <br /> A <br /> G Facility Name A {� C /- ) / , if* /Lj C. r { f?cl 14 Phone # ( Z C,0 ss <br /> � Address Z S 71 � sC! 1 . �. �G. ,-� '!rte; c �, C ' A S D 4 'I <br /> Cross Street S74 c7 <br /> T -- - <br /> Y OwnerlOperator e + •�� Phone K S i e ) j <br /> "L 'i <br /> C Contractor Name <br /> O ' wylPhone # <br /> c <br /> T Contractor Address .761 k ilH , C—} • �, CA 9y Sc' ^r CA Lic # Class <br /> R Insurer c � 4 t �io `�^ r, d Work Comp # O2 / r ( l,f' 21 <br /> cICC Technicians Name <br /> T ' C' .� , t d �. (�, �* , . c �1c Z Expiration Dale 20 2 .7 <br /> D ICC Installer' s Name ( S j, Expiration Date <br /> R l., .7 f !. v _ f-.., f� f L P 41 <br /> Tank system work area Date UST <br /> Ll p 87 po.i <br /> 11=9 Sump. 91 lk detector. UDC 1 /2, c1c. 1 Tank Size Chemicals Stored Currently <br /> — _ _ Installed <br /> T T ► : � � S / c� I' s' <br /> P Approved Approved with conditions Disapproved <br /> L (See Attachment With Conditions ) <br /> Ai 1 <br /> N Plan Reviewers Name C/ a 'f Date 10 " 2 2121 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAI\ <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS 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 TC <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 ("Je Title i ( l }1 L' 17 e<lz' Date <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 / /� 1 / �i �c' TITLE U PHONE #�� <br /> ADDRESS Z S S ?fs cLe. <br /> SIGNATOR // 61a 1 Gf � 40/ DATE <br /> 2of6 <br />