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ENVIRONMEN:TQL HEALTH. DEPARTMENT <br /> SAN-JOAQUIN COUNT Y <br /> OO-Ea-stain-Str4et�-St-ocktonT affor-nia-9.520 <br /> Telephone:(209)468-3420 Fax: (209)4683433 <br /> APPLICATION FOR UNDiERGROUND.STORAGE TANK RETROFIT OR.PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE:.INDICATE PERMIT TYPE BELOW: <br /> [Q.TAMC RETROFIT ❑ PIPING REPAIRIRETROFIV ❑ UDC'R"EPAIWRETROFIT ❑:COLD'STARVEVR[UPGRADE <br /> F-. I=PA Site# Project Contact&Telephone# - <br /> C Facif" blame - <br /> - C qty. �' Phone# <br /> Address <br /> I .'Gross Street. . <br /> Ownerl0perator. :Phone-#: <br /> c Contractor:Name Phone# <br /> t ' <br /> N Contractor AddressA Lic# Class <br /> �. <br /> :A' Usurer' _ .Work"COmp# <br /> 7 . <br /> . ICC Technician's Name Expiration Date <br /> R <br /> ICC Installers Name Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently -Date-UST <br /> (La 87 pl;M6 sump,91 leek deleclor,UDC 1/2.elc.) installed. - <br /> T <br /> A <br /> P 0 Approved "Proved with conditions ❑ Disapproved <br /> L '(See Attachment With Conditions)' . <br /> A . <br /> Plan.Reviewers tJame- r � 1� - - - Date L`li 1 <br /> 'APPUCANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JO. <br /> A©UIN..COU NTY ORDINANCES,STATE LAWS,.AN'd RULES AND REGULATIONS OF SAN <br /> JOAQUIN'COUNT'Y,ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENTS'SIGNATURE CERTIFIES THE:FOLLOWING: 'I CERTIFY THAT IN <br /> Z}fEPERFOi3MIANCE OF.THE WORK-FOR WHICH THIS PERMIT Is ISSUED,'!SHALL NOT EMPLOYANY'PERSON_IN SUCH_A M8 NE};_fl$TO:BECOME.SUBJECT" <br /> �'O'WORKM'S COMPENSATION LAWS OF.CALfFORNiA.".CONTRACT'OR'S HIRING.0.SUBCONTRACTING SIGNATURE CERTIFIES THE,FOLLOMNG: "I CERTIFY, <br /> Y ., <br /> T}{ATIN THE PERFORMANCE"OF THE,WORK FOR.WHICH THIS�PI:RhEr(!S 15SUED,J.SHALL EMPLOY PERSONS SUBJECT TO.WOR KER�S COMPENSATION LAWS - <br /> OF,CAt112ORNIA'. <br /> r y{Rpjanrs Signature Title Date <br /> i <br /> BILLING INFORMATION. <br /> ladicafe the responslbie party+.to be bifled for'additional ERD staff-time expended beyond permit paymedt.coverage.per tank. If <br /> fie:party designated;below 'is different than the:'permit..applicant,.e.g:`property owner, .the party, must-acknowledge this <br /> responsibility far the billfng-by signature and datebelow: ; <br /> t NAME I �' ILt1I TITLE !J"# 1GPHOAlE,1 f � <br /> r [ <br /> A DIAES L1 ` ' <br /> it <br /> SIGNATURE C><`� 1 '� DA. �f��- <br /> EH23403$(revised 02!20109) <br /> Z.. <br />