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SANJOAQUIN Environmental Health Department <br /> -- COUNTY <br /> — <br /> A ' 0 ; , 2020 <br /> AP <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERI14l1XjVIHONI MENTAL H EP LTH <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 /> � Facility Name j ✓qV, 0J0,k " W 6c6J 5 j Phone #C?, OC1 <br /> L Address � 007 <br /> C tj 2, 2 <br /> TCross Street j.E��` jAcc-F'oa� '`� '� <br /> Y Owner/Operator of&' pia <br /> + jtN � � �(( Co . Phone # <br /> C <br /> Contractor Name - ctkqAt�o Phone # <br /> N Contractor Address 17,1 G f CA Lic # 0Z v J Class taJ <br /> T <br /> A Insurer w $VAe, 44 CAV cs;arp, �t 611 63� <br /> kR( Work Comp # Vf l 6 1 j0 <br /> T <br /> ICC Technician's Name �-1� 7C. � ( �, Expiration Date �T�jZ'r�j 2 ( jra , C <br /> Expiration Date <br /> R <br /> ICC Installer's Name z,l/` �µ C�.f� rjZ ��L�tj $�} <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 lfb7 5 ( 0 c� C <br /> Nyr�yi�* \ / �+ 0 a/" p p F1 <br /> P ❑ Approved tyl Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A 1 + <br /> N Plan Reviewers Name a`^- ` $v 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." /) _ / r�, _ u/ <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 (fpty • 1,0ekaw L�G . '}-SC.. " TITLE ." PHONE # (3tCw) 024 1 <br /> ADDRESS\751 751 O 1 � � )6e4 L ' <br /> SIGNATURE 1W DATE <br /> 2of6 <br />