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RECEIVED <br /> SA N J O A O U I N Environmental Health Department <br /> ---- COUNTY -- - --- w! AY V! ?. 019 <br /> APPLICATION FOR UNDERGROUND STORAGEVA1RONMEN AL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT OEPART11ENT <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 # /noon& Vel 0V 9jG <br /> A <br /> C Facility Name (� G Phone # <br /> Address d� (� <br /> TCross Street <br /> Y Owner/Operator Phone # <br /> oContractor Name /Ne . Phone # Q'/& <br /> T Contractor Address 8 �pLep,,, �t"� CA Lic # 7 g3F' Class <br /> A Insurer Work Comp # j`p '7 .3fD ? 5 / <br /> T ICC Technician 's Name i C Expiration Date `? � ei — Oicire <br /> R ICC Installer's Name �fj�f� �c] Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T 7 ,� c.t_ � Z2 <br /> A <br /> N <br /> K <br /> P ❑ Approved with conditions n Disapproved <br /> L 6Approved <br /> achment With Conditions) <br /> A <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDA H 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 PERFOR ANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." �r� .�. �1� <br /> Applicant's Signature Title <br /> �/�' /'v7r�72nen- 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 and date below. p <br /> NAMEE� ��/(/�®R� TITLE �/���- PHONE #__ ! <br /> ADDRESS pe <br /> SIGNATURE DATE <br /> 2of6 <br />