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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 'I�UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Use O '40-94-60:39 <br /> 3 <br /> � Facility Name Q, � .S UQ�.Q� , ��� �y Phone#Qjtj -V4q-- Q-1 (Q� <br /> I Address jl'37 W LOVA(k151 T� C S..�3 <br /> Cross Street <br /> TPhone# <br /> Y Owner/Operator "8�, ��-�e. R'06L O RA <br /> C Contractor Name �j T' �_ Phone# fk <br /> N Contractor Address 3a-a P- ( �( -P� CA Lic# 310 +' Class <br /> T <br /> R Insurer �'. Work Comp# <br /> A <br /> T ICC Technician's Name Expiration Date <br /> T <br /> R ICC Installer's Name Expiration Date <br /> f� V' 06 9t 9,QbN P �( <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 <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name �'�' 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 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." / 4 <br /> Applicant's Signature Q �h� l.1/`Title `�`tl Date 1 <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 billinggyyb�signature <br /> �and <br /> � dat'enbelow. <br /> �c� ��/s �f <br /> NAME i�r\ l �l ' �' rIu�" TITLEl��` e V�` PHONE# �C� `0+1 -�Q(� 0 <br /> ADDRESS <br /> r1X <br /> SIGNATURE <br /> .tom+ l�C/4.L� DATE V / 0 ! �+iJ <br /> 2of6 <br />