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SANJOAQUIN Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE . INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT [IPIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE l,' ' <br /> F EPA Site # Project Contact & Telephone # �l skar `A ZEQ� °J¢,Z rOO68 X <br /> � Facility Name GLt' TVIA41k� 44/LW Phone # Zvq X 43 - 5 ,213 <br /> L Address <br /> TCross Street <br /> Y Owner/Operator d 44' "til ie V . (2p Phone # j 5r,02 j,5- L e30! a , 2 <br /> C Contractor Name �� ( pr ( u Ot t Phone # /fO v }¢-2 ° PB (z,0 <br /> N <br /> r Contractor Address 113o Awes A /� . CA Lic # 3ej [:,S7S Class ftB C - lip 8,1Z <br /> A Insurer Eel fi01�) F4md CA Work Comp # `103c( ;Z ' 20 M <br /> T ICC Technician' s Name � 6e4,� neA;M,t Expiration Date 1 , "7I1311 dj <br /> R ICC Installer's Name � �iX�✓ 1` �lzvt,t.Li' i� Expiration Date I Z13d1141 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i .e . 87 piping sump, 91 leak detector, UDC 1 /2, etc.) Installed <br /> T U S <br /> N sed is ( f7tl 5L: v � used n I u-s1 <br /> K <br /> P ❑ Approved IkApproved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name. Ow a ! � � ( ( w Date 0 <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 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 /> 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." <br /> Applicant's Signature Title Date <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 n <br /> his res`po'nnsibilit'y for the billing by signature and date below. / /� / Q/ <br /> NAME I�CCLL, a E "fir( TITLE I" I A PHONE # T `)�� TJ 2 Ob v✓ <br /> ADDRESS i `ti S / ' EiLL�-� I P ( I �i S � (/� ' ✓� " ✓�� <br /> SIGNATURE DATE <br /> 2of6 <br />