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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />- 600 EastMain3teeet; Sto ffon; C foxmia 3202 -- <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br />- THIS PERMITEXPIRES 180 DAYS FROM THE APPROVAL DATE:. INDICATE PERMIT TYPE BELOW- <br />IT TANK RETROFIT.❑ PIPING REPAIR/RETROFIT DC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />- F-. EPA Sife # - <br />A. Project Contact & Telephoned# <br />C Facility Name - Phone # - <br />Address_ - a 4 -.J a�� <br />-.l Cross Street - <br />Y : �Owner/Operator Y- .Phone #' _ <br />C' Contractor Name - <br />o' ,I -. Phone.#� <br />N Contractor Address �� <br />T ALic#' ClassAb lJ�cn <br />R Ipsorer` W <br />A Work Comp # <br />T <br />D ICC Technician's Name - - <br />- - Expiration Date - <br />R ICC Installer's Name Expiration Date <br />Tank system work , u c Tank Size Chemicals Stored'Currenti Date UST <br />(Le. 67 NOW n^^F. 91 loew aemelm, uoc lit, er! y Installed. . <br />- T - - <br />A _ <br />N <br />P ❑ Approved. Approved with conditions ❑ Disapproved <br />_ L. (See Attachment With Conditions) <br />q. <br />N plan Reviewers Namet..N �.va,�l�.: .. Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SANJDAQUIN.COUNTYOTIDINANCES, STATE LAWS, AND RULESAND REGULATIONS OF SAN <br />JOADUIN COUNTY, ENVIRONM[NTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S' SIGNATURE CERTIFIES THE FOLLOWING: 9 CERTIFY THAT IN <br />_1FIE_PERFO$M9NCEOF�}1E iNDRICFDR_WHICH-THIS.PERMrr 1S 18SUED ISHALt+NDT EMPl:01^ANYPERSOIJ:IN:SUCH A-MWNF97;S Y013ECOME.SUBJECT <br />- 'TO-WORKER'SCAMPENSATION IA,WS OF.CACIFORNIA`,CONTRACTORS HIRING.OR SUBCONTRACi1NG SIGNATURE CERnFlES THE FOLLOWING: 'I CERTIFY <br />iHpTINIHEPERFORMANCEOFTHEWORKFO WMICHTHISfERMRlSISSU[:D,I;SHALLEMPLOYPERSO SSUBJECTTOWORKER'sCOMPENSATION LAWS <br />OF CALIFORNIA' ..:. : <br />AppttranCs Sigrmnire `.. Dafe. .. <br />BIWNG INFORNIATION:,:i . <br />Indicate the responsible party'to be billed for additional C -HD staff fame expended:beyond pennit.:paymant Coverage per tank. If <br />the party desig ted below different than the permi[. applicant,` e.g. property; owner,: The :party must; acknowledge this <br />responsibilitLyhppfor 7TeT billing by Signature and date below. -r.-1-.-!' <br />NAMEEII7V .L1L .1 LJI IIIQ (.I �.Ir lY lull �}11 II/'1 PRONE 13 1 U7. 1 <br />TITLE t .. <br />ADDRESSIan) 0 <br />WlbW 4/i -, <br />SIGNATURE_ - DATE <br />: EH230038 (n sed M2 0109) - <br />1 <br />