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SANr=J U A Q U I N Environmental Hea 6 pa <br /> APPLICATION FOR UNDERGROUND STORAGE TANKNVIRONM611 I._ 11 -REALT <br /> RETROFIT OR PIPING REPAIR PERMIT DEI'�ARTPVIEW.. <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A <br /> C Facility Name �� ;AoAl d Phone # z o g � - Ol <br /> Address <br /> 1 Cross Street <br /> T <br /> Y Owner/Operator Phone # <br /> oContractor Name J� Phone # <br /> T Contractor Address CA Lic # D03 y5� Class/Q CZ/ cio,IIy <br /> R InsurerWork Comp # CA ) 000,,.j73y_ / <br /> A UZi✓ / Al I G AC , Co , <br /> cT ICC Technician's Name U y 7 Expiration Date <br /> R ICC Installer's Name d h ,,� 0 7 Z S� Expiration Date 3 V12 02 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. X /87piping sump, 91 leak detector, UDC 1/2, etc.) > Installed <br /> oevo <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions L] Disapproved <br /> L (See ttachment With Conditions) <br /> A ) _ <br /> N Plan Reviewers Name , • tJ Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENTS 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 /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." G� <br /> Applicants Signature Title c Z rq 2 C Date Z / / <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 /> acknowledge this responsibility�G for the billing by signature and date below. / <br /> NAME �G z Lr /� S � r m% TITLE �� r e LZl et 7� c44 PHONE # �j/� R 3 41 1 7l <br /> ADDRESS 30 �4 in 4v z , .5 ; � �5h Z16 (�5iL/;! 5 ep2 y <br /> SIGNATURE DATa� A41 <br /> 2of6 <br />