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I7 <br /> SANJ Q A Q U I N Environmental Health Department <br /> (, OU r\ll- Y FF. B 2 4 2020 <br /> APPLICATION FOR UNDERGROUND STORAGBT NK ,,., ENTAL HEAL fAH <br /> RETROFIT OR PIPING REPAIR PERMIT a_ , . + 'ARTMENT <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 <br /> C Facility Name Phone # Zoq <br /> L Address If�j P ert e <br /> TCross Street <br /> Y Owner/Operator Phone # 9 . S\76 . j <br /> FContractor Name lC Phone # ( <br /> C <br /> T Contractor Address , CA Llc # 19 Ct 01 Class <br /> AInsurer - Work Comp # <br /> TICC Technician's Name Expiration Date <br /> DICC Installer's Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 81 leak detector, UDC 1/2, etc.) <br /> + Installed <br /> T ` t <br /> A <br /> N <br /> K <br /> P ❑ Apprc• ' P ' a mpproved with conditions ❑ Disapproved <br /> L )NI e Attachment With Conditions ) <br /> N <br /> Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JO QUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN 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 IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> ORKER'S COM NSATION LAWS OF CALIFORNIA ." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PER RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> ppllcant's Signature Title - C Date U211 a7 C ) <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. � � I <br /> NAME �� 1 � i� ei � cLi TITLEr { <br /> # <br /> ��, /` ' �n �/` J n n rLoPHONE fir ' C�33 h(w 1 <br /> ADDRESS % 9O e r <br /> SIGNATUR DAT 0 2 2O Zp <br /> 2ot6 <br />