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SAN =10 A Q U IN Environmental Health Department <br /> — COUNTY - <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> 0 TANK RETROFIT 0 PIPING REPAIRIRETROFIT 0 UDC REPAIRIRETROFIT 4COLD STARTIM UPGRADE <br /> F EPA Site # CAL QnOyO Z 1S0 Project Contact & Telephone # jc5sG ewdi ?Dy 605= 0 <br /> AFacili Name Phone # C2cj <br /> C Facility OSCv✓� � d r7 � e.. © Avn P� <br /> Address 11? r1 r . Yas� •�-> �` Ave. ,x,,,, �,� Cie 915'336 <br /> T Cross Street Ba ¢f v,,, Avy <br /> Y Owner/Operator ss,� /' 7e d do Phone # ZoS 6011 - 0// V. <br /> o Contractor Name t r. K4 �(� t %dr „ St.r 2l, Phone # C4 Z !r O— OJO.? <br /> N Contractor Address 3Z I jt k , C+ A „ 4� or {� g �-p CA Lic # / ew S'Y YY Class <br /> T �� <br /> R Insurer S"44e. dodo + cr,s c '; vt. 1.:%w" 4.. �v,n 3 Work Comp # ` a /Y 7''94°- z3 <br /> A <br /> T ICC Technician's Name t"� e. gq ( .S 4o" d ke a„ Expiration Date Y / Zo 2 5' <br /> DICC installer's Name CPhve .Ad ( 306Md ltd z _ Expiration Dale / �zp 2aZ,S' <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (o.a. 87 ptpm8 sump. 91 tad dalactw. UVC 112, ata) Installed <br /> T Tl rt <br /> t� l( S gp r+ Y'1 ,S' 9 17 <br /> A Ole S� i F'tIt <br /> N <br /> K �-�� I S" r`f t F• l �� / t <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A yy <br /> N Pian Reviewers Name i4S o Date <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 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 TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 01 CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR M CH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> Of CALIFORNIA.' _ ,/'� <br /> pgeartt'e Signa V <br /> T111a W o7 e r Data <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 responsibilityfor the billing by signature anddatebelow. <br /> NAME e�-.5SG ChAdd � TITLE UW ne / - PHONE # L2p0 60 c <br /> ADDRESS y.!« i 4 4ie / c" >rca 6A n" ri 03 6 <br /> SIGNATURE P)WAO DATE_ <br /> 2ot6 <br />