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SANS UMIN <br />—COUNTY— <br />Environmental Health Department <br />APPLICATION FOR UNpERGROUNO STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPtftES 180 DAYS FROM T E PPROVAI DATE, INp{CATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT 0 PIPING REPAIRIRETROFIT H)(UDC REPAIRIRETROFIT O COLD START/EVR UPGRADE <br />F <br />EPA Site if <br />Project Contact <br />& Telephone # r�&h ee ZpQ S G�_ yya/y <br />C <br />Facility Name AACO .tt= ?323 v <br />Phone # 112 Oq$y� . b00 <br />L <br />Address J40 <br />W Cool 0��.1 <br />ceA `i r24 4 <br />s <br />1 <br />Cross Street Y'C, a ye <br />Y <br />Owner/OperatorkaAWN-{- <br />S) >1 1A <br />Phone # ZC9c) hw"4C7. Afolef <br />o <br />Contractor Name tQ <br />tj <br />r � (lew^^ wtf,c�y <br />- <br />Phone y�- y {�. pgp3 <br />T <br />Contractor Address 3 <br />%A C+ v CA 4 <br />CA Lic # /040s t/t1tl Class <br />R-11 <br />A <br />STInsurer -ttC <br />Ev1 Q. .�� Jn <br />!4» 1LS'W'Qna� <br />`L <br />Work Comp# ZI <br />T <br />ICC Technician's Name <br />Expiration Date 2O2�4 <br />RD <br />ICC installers Name <br />' <br />CU cc 5,L04.,c 4e <br />Expiration Date <br />Tank system <br />work area <br />Tank Size <br />Chemicals Stored Currently <br />Date LIST <br />p.e. 87 piping sump, 81 loak detector, UDC 1/26 etc.) <br />Installed <br />v �- 4& 2 L) <br />r )c <br />T <br />N <br />U G �' �- <br />L) <br />K2.- <br />u� 134 y <br />Ls 0C /!;"et /,6 <br />P <br />Approved with conditions <br />Disapproved <br />L <br />A <br />(See Attac ant With Conditions) <br />N <br />Plan Reviewers Name <br />�y <br />Date <br />APPLICANT <br />MUST PERFORM ALL WORK IN WCC ANCWITH SAN JOAQUIN COUNTY <br />ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTM NT. OWNER OR LICENSED AGENTS <br />SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK <br />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 <br />OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br />THAT <br />IN THE PERFORMANCE OF THE <br />WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA" <br />Applicant's Signature <br />I� <br />R Title �7 <br />Date b -�� <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 />acknowle5i;ie this responsibility for the billing by signature and date below, � <br />NAMEL1� b% l,T`�(E #C <br />TITLELC/l%G� ✓� PHONMZ D ? <br />SIGNA <br />L- <br />3of6 <br />