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SANJOAQUIN Environmental Health Department <br /> COU NTY -- <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 ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A Facility Nalrle t IL /G Phone # 424W 94 r - 40 �7 <br /> I <br /> L Address 575 <br /> TCross Street <br /> Y Owner/Operator i9 v�s Phone # <br /> oContractor Name Phone # <br /> N Contractor Address 4 CA Lic # 2 �p �Q3 Class <br /> T <br /> R Insurer Work Comp # 1, 07307579' <br /> A <br /> c ICC Technician ' s Name C57 /`C � /�,� Expiration Date <br /> RICC Installer' s Name E. Expiration Date <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 uvc '7/ <br /> N 1 SM�TP i er <br /> K Ct If A7 [.t_ 5 t9AID <br /> P ❑ Approved Ipproved with conditions ❑ Disapproved <br /> L (S achment With Conditions) <br /> A � 5 <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANC JH 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 COMPENSATIO LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : " I CERTIFY <br /> THAT IN THE PERFORMAN 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 responsibility for the billing by signature and date below. <br /> NAME / I gg&� TITLE ����� PHONE # \qZl9 ' 0) 10S DS fs�7 <br /> ADDRESS / 6 1C �� ?!SE766 <br /> SIGNATURE DATE <br /> 2 of 6 <br />