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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 ❑PIPING REPAIR/RETROFIT XUDC REPAIR/RETROFIT U COLD START/EVR UPGRADE <br /> F EPA Site# L0.Lo 0,0-Lb0-7b S Project Contact&Telephone# 16 (=1y , <br /> 110-32A <br /> C Facility Name / Phones# 2� / -12.�(o00 <br /> � Address � 5 \. �RCIC�( P\\As- ��Lk'Cb►`L �A :1P)2d-7 <br /> I Cross Street Ovb <br /> T <br /> Y Owner/Operator �D' NIFq� -V-6 Phone# 14161- 3ovC <br /> C Contractor Name 2M"?,1 rb4A-c►1 Phone# _1032- <br /> 0 <br /> N Contractor Address 'L D t�`1 PC�� � � 4�V CA Lic#2 v�b Class A H Z <br /> T <br /> A Insurer 41111 Fl,R.0 Work Comp#51WE R \ 60 2.1) <br /> T ICC Technician's Name �?HZrl b,0 Expiration Date 'ZpZ 0 <br /> R ICC Installer's Name RNNAKW T`kN4D QO,4 0 Expiration Date 2 Q Qw <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.) 1 Installed <br /> T Q 2n nou (i L v �c u� �r�`� LA 200 <br /> N �Z F LL 5� S O� � S 2-,Dc)q <br /> K O nC� A1C 7�M wo ( Z f1� <br /> L C v -\�*t S S I A V\- VZaDJ 5 Z v0 <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (SXeAftachme Conditions) <br /> A <br /> N <br /> J� <br /> Plan Reviewers Name :>Q/ �Q Date C� 7 /r <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMEN AL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF TH Of FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATI SOF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMA THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATICN LAWS <br /> OF CALIFORNIA." � <br /> Applicant's Signature Tit ` Title�&Oji(j ` IkCA�Fk 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 responsibility for the billing by signature <br /> and date below. n <br /> NAME (_A'51a 6�. PS TITLET` 0 J U I`N I�G�1� PHONE# 0II2r71 ACn-)U 32 <br /> ADDRESS Io <br /> SIGNATURE DATE A% \0 <br /> 2ot6 <br />