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APPLICATION FOR UNDERGROUND STORAGE TANK molymayIAL <br />RETROFIT OR PIPING REPAIR PERMIT ARTMENT <br />THIS PERMIT EXPIRES t8O DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW. <br />3TANK RETROFIT 13 PIPING REPAIRIRETROFIT r - UDC REPAJRIRETROFIT t;COLD START IM UPGRADE <br />A <br />EPA Site Contact & Telephone c�b 9- 40 q- q <br />C <br />I— <br />FF <br />Facility Name D5CAtit ±C, Phone# <br />L L <br />Address <br />TT <br />Cross Street <br />Y <br />OwnerlOperato I "Suytn's'l r Phone# <br />C <br />0 <br />Contractor Name 'Say. Phone# <br />N <br />T <br />Contractor Address is Class <br />A <br />C <br />Insurer 5't,41ET E, FIA tQ b Wori(Comp # 969575-e- 2-019 <br />T <br />ICC Technician's Name "Lop &kl Ae Z- Expiration Date Oq - 2,j) .-/57 <br />0 <br />R <br />ICC Installer's Nam C2ua Su.mche,-- Expiration Date 12--O?-Iy <br />Tank system work area Date UST <br />(Ea 87 piona sump, 91 leakdatector, VOC 112, M) Tank Size Chemicals Stored Currently Installed <br />T <br />A <br />N <br />K <br />P <br />J Approved F1 Approved with conditions7. <br />— Disapproved <br />A <br />(See Attachment With Conditions) <br />N <br />Plan Reviewers Name Date <br />PPJGANT MUST PERFORM ALL WORK IN ACCORDANCE 'OATH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOACUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S. 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 FOLLOWNG: "I CERTIFY <br />THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS P§RM7 IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAINS <br />OF CALIFORNIA," <br />/10 <br />jAppk2rWs Signature_ - V I- LTIt <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. <br />NAME 0AbffA--U-)- &Lrr)kaj:�= TrTLE-Cf)r1'* 7 <br />DIU —4 �;fi V- PHONE �OLJ— 9 33 0 <br />2 <br />