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RO ME TAL ATH EAR MENT - <br />SAN JOAQUINtOUNTY <br />600 East Main Street, Stockt n, California 9502 <br />Telephone: (209)-468-34'20 ax: (209) 468-3;433 <br />APPLICATION FOR UNDERGRC UND STORAG TANK <br />RETROFIT d PIPWG FiEPAIR PERMIT <br />THIS PERMIT;EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMITITYPE BELO <br />❑ TANKRETROFIT ❑ PIPING REPAIR/RETROFIT ❑UDC RE AIR/RETROFIT ❑COLD ST RT/EVR' UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # 61110 <br />A <br />_ <br />C <br />Facility NameSib�a+ Pho e #P4 , <br />I <br />L <br />Address <br />.' <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # a <br />C <br />D <br />Contractor Name <br />Phone <br />N <br />T <br />Contractor Address CA Lic # Class <br />R <br />A <br />Insurer�'. MA n lullWor Comp Cl E, <br />T <br />(CC!Technieian's NameA <br />Ex0ation Date <br />R <br />icc installer's, Name Expiation Dat <br />Tank system work areaDate <br />(i.e. 87 piping sump, 91 leak detector, UDC 1/2, etc.) <br />Tank Size <br />Chemicals Stored Currently <br />UST <br />Installed <br />T <br />A <br />N <br />K <br />i <br />P <br />❑ Approved A roved with conditions pp <br />PP Pp ❑ Disapproved <br />L <br />A <br />(See Attachment With Conditions) <br />i <br />N <br />Plan Reviewers Name Date r� t <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAW $, AND RULES <br />AND REGULATIONS OF SAID <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTtRES THE FO_ <br />THE PERFORMANCE O F THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY ANY PERSON IN SUCH A. MANNERAS <br />LOWING: "I CERTIFY THAT I <br />TO BECOME.SUBJECT <br />WORKER, S-OOMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBC NTRACTING SIGNATURECERTIFIES <br />T q <br />THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WHICH THIS PERMIT IS ISSUED, I S1H�,AtL,i EMPLOY PERSONS SUB ECT TO <br />OF'CALIFORNIA" . <br />RKE/'R'S COMPENSATION LAWS <br />`WORK \FOR <br />. <br />(Wj <br />Applicant's Signature � �. )� t � ) , _ Title he S 1[ f C Ni ) Data (0 j '1 <br />1"i <br />BILLING INFORM' 101\1: <br />Indicate the responsible, party to be billed for additional EHD Staff time exp nded beyond permit payment coverage per tank. If <br />the pa�oy . designated below is different than the permit' applicant, e.g. property owner, the party mint acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME �� 1-[E -[ i�C�t`f� t r C1C TITLEVP ' W 9 PHONE # <br />ADDRESS i S62013 - <br />SIGNATURE DATE <br />EH230038 (revised 08/1/11) <br />2 <br />