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SANJOA Q U f N Environmental Hnalth Department <br /> -- COU N l Y - <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS HERMIT ExPItALS 1W DAYS rRDN THE APPRCNAI . (A4TTE. INDICATE PEMUT TYPE GLLG : <br /> TAf' it"f RETROFIT i i PIPING REPAIWRETROFff D UDC REPAIRIRETROFIT G COLD STARTiEVR UpGq ADE <br /> F ENA Site # C41 h jTT 1 Projrct Contact & TedGphone �l ��� �v , Ale f � ;�y 04w <br /> Faci6tyNamoC r�r4' J� <br /> Phone <br /> L Address j5" 5'0 W � ; c f cl -1 _C3 S <br /> 1 Cross Stred <br /> Y Owner/Gperator 6d�2 — �'� Z K2 t i - Phone <cq, 4.57) <br /> NContractor <br /> Name <br /> 14 „�n o r% L � <br /> P�'� ro j'� Cg r vo it rT " L ' P>>on 'Lim)o # - `a' �0 <br /> T Contractor Address �� 1, tic�c�I CA Sy�aq ( GA tic # S e/ y Gass /4 <br /> R InavrPr + _ <br /> A '�4 `K Co 4nrr 4 "X;A 3 <br /> C Vnev %4CC lSL%dp Work Comp # <br /> oICC Techr,� ny 's Name <br /> C� vG, 4 gtau C �r<. z Exfsiratxtn Datef - I . 20 Z <br /> R ICC Installer's Name �, �u� a, � i t Ste. s +'ic 2 . Expiration Date ^ f Y - <br /> Tank system worookea area Tank Size Chemicals Stored Current) Date UST <br /> msT �pwa�. e� w,+< e+IeaY, ekJ y <br /> Installed <br /> T <br /> HZ ' <br /> Doe <br /> 1P Approved �J Approved with conditions i Disapproved <br /> A <br /> A (See Attachment With Conditions) <br /> " Plan Reviewers Name ° DateAPPU <br /> I <br /> CANT MUST PERFORLi ALL WORK IN ACOORDMCE wfTH SM �OAOUIh COUNTY ORIkNMNGE3, STATE PAWS, AND RtJf E5 AND REGULAT10tes OF SA <br /> OAOUN COUNTY, rarVIME WO TAt HEALTH DEPARTMICSVT. OWNER OR LICENSED AGEHrS SIGNA7uRf CERTIFfP3 T:1E rOLLOwING: 9 CERTIFY THAT I <br /> HE Pt3trORNAr�E OF THE WORK rt)R W1 tIC I IIS PERMIT I$ ISSUED, I $HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME STIBJHCT T <br /> RK[RS CO&VENSATION LAWS QF CALIr CONTRACTOR'S 10RINO OR SUBCONTRACTING SIONATURI_ CERTIFIES TFC FO drYlalG •1 CERTIF <br /> THAT NN THE PERFORh1ANCE OF THE 11'l7f�C F R • 'H THi3 PERMIT IS iSSUED, I SHALL EMPLOY PERSONS SUR,IEOT TO WQR RS OMPI NSATIUN LAW <br /> OF CALIFORNIA ' <br /> �. IdW <br /> BILLING INFORMATIOV , <br /> Indicate the responsible perry to be billed for additional END staff time Cxpended beyond permit payment coverage per <br /> tank 11 the party designated bolow is dllrerent than the permit applicant, e.g . property owner, the party must <br /> acknowledge this responsibility for S'tithe billing by signature And date below. <br /> NME Ed SCI r 4 Q ) <br /> 1 f p�TIITLE C e4 PHO?& 9 2 S c1cf _ cif f0 <br /> ADDRESS V� W. �Gyn , Cts l� c I r'r, C CSI �i ir? 3 6 <br /> SIGNATURE 1 DATE ` J <br />