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AJ O A Q U I N Environmental Health Department <br /> CCuN1TY l !� <br /> APPLICATION FOR UNDERGROUND STORAGE TAN <br /> RJETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT E MIRES;eo QAYS FROM THE AP PA UjAl.DATE. rNmCATE PERMi T T YFE aELO . <br /> O TANK RETROFIT ❑WIPING REPA4IMETROFIT 19 UDC REPAiFURETRQFTT ❑COLD STARTIEVR UFIGRADE <br /> F E?A Silo# Pfaject fionitad 6 Telephone# - <br /> FacflRy blame Fast and Easy Mart#103 Phone# 209477-2844 <br /> I Atddress 8WO N Linm Sacramenla Rd <br /> 4 <br /> T <br /> Crass Street Ponce De Leon Ave <br /> y Ownerf0perator Phone <br /> C Contracbor Frame JEC Services Phone 0 Q16-993-6312 <br /> 0 <br /> T Contractor Address 4901 Warehouse Way SavwmentG CA CA l iz# ClaSS A-I1I-040- <br /> R* Insurer, L-P ITSLaICe 3erves ark Comp# <br /> T ICC TeOrliCian'S fume Oscar Negrete Expiration Date 611312027 <br /> ICC InstaAers flame Expiration Date <br /> Tank system wo&area Tank Sf�e Chemicals Stared C+ufenity Date LEST <br /> OL&U q�r.gp,9I reY*M*t r,UCC uz fti Installed <br /> T <br /> A <br /> N <br /> 'K <br /> p Ap ed with ccr[ditiorls La 0haeppraved <br /> (S A e twn th Conditions} <br /> n 7/15/26 <br /> Plan Reviewers Brame Date <br /> APPUCANT MOST PERFORM ALL MRX IN ACCORDANCE VATIA SAIN JOAQUIN COUNTY MCI[NANCES,STATE LAWS,ANO RULE$AND REGULATIOM OF SAN <br /> J OAQUIN COUNTY,ERVIROMMEWAL HEALTH DEPARTMENT.OWNER OR UCENSED AGENTS 51C,NATVRE CERTIFIES THE FOLLOW KG: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERNT IS ISSUED_1$11ALL HOT EMPLOY ANY PERSOk IN SUCH A MANNER AS TO 11E:COMR SLMJErT TO <br /> YJORKEFL'S COMPENSA7ION LAWS OF CALIFOfLIJiIA-' CONTFMTOWS hiit1NG OEM SkJOCONTRACTING SIGNATURE CERTIFIES THE POLLOMNG; 'I CEPMFY <br /> AT IN TtlE P$kFORtAkNC$OF THE wORK F R V"CW Tri1S PERMIT IS ISSUED,I SKA,LL EMPLOY PERSONS SQRJEGT T777 <br /> 'S CONIKASAT[ON LAWS <br /> F CA,LIFORNIA,- 1 <br /> Plic.n{ 546alurs title' F 4 Date � ' <br /> 0 ILLI N13 INFORMATION, <br /> lndicale the responsble party to bra billed fGr additional EHD staff fime expended beyond permit payment coverage per <br /> tank. If lt[e pally designated below is different than the permit appllcant, e.g. property ovmer, the party must <br /> atd=vded this respo ibillty for the billing by signature nd dale below. <br /> NAIVIS ' � ' `� TITLE {rr*l!f L PHONE# { f <br /> SICOATURE E)ATE <br /> aof6 <br />