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SA NdO A Q U I N Environmental Health <br /> E <br /> —COU NTY— <br /> 2 12018 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT ENVIRONMENTAL <br /> THISP RMIT EXPIRES 180 DAYS FROM THE W�gPROVAL DATE. INDICATE PERMIT TYPE BELOW 'IE�?I.T 11�EPARTMEf�' <br /> 13 TANK RETROFIT (PING REPAIRIRETROFIT S4JDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> FF <br /> EP2—!Zo <br /> p p 1t f 5g Project Contact&Telephone# j1()�'11,�b-0Fa /� �S � r= *4Ap'- Phone#AdqCro <br /> Y Owner/Operator ioi ex S r - Phone#Z .101- 1461- 33 <br /> c Contractor Name E`t ` +, <br /> D ne# <br /> N Contractor Address rt. <br /> T S3S Lid hlpr►1 p r CA Lic# l Class <br /> AInsurer <br /> C Work Comp# <br /> T ICC Technician's Name Expiration Date <br /> ]RICC Installer's Name <br /> Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> p.e.8�7/p-ipy�q wmp.91 leek tlelaaa.UDC 112 ete) y Installed <br /> ` A v G's '�h <br /> K <br /> P ❑ Approved 6Approved with conditions ❑ Disapproved <br /> L hment With Conditions) <br /> ANPlan Reviewers Name � L Date_ <br /> PPLICANT MUST PERFORM ALL WORK IN ACCORDAN 4TH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S 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 /> RKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY <br /> W <br /> AT IN THE PERFORMANCE OF THE K FOR WHI IS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> icanrs Signature <br /> G 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 bell W. I y� <br /> NAME 3 ( rv� TITLE �' " v` PHONE# �` y 3 0 <br /> ADDRESS �-t�-� �'�J���/I� r-i �Y��/I �T�L� Ta�1 oA <br /> SIGNATURE DATE <br /> d Q� <br /> 2 of 6 <br />