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V E""D <br /> SANJOAQUIN Environmenta H arfMLnti <br /> cou NTY--- ITEC 01 Z01i' <br /> APPLICATION FOR UNDERGROUND STORAGE TANI'ENVIRONME.d TfkL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT DEPT APTIMENT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMITTYPE BELOW: <br /> I TANK RETROFIT ❑PIPING REPAIR/RETROFIT VUDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# <br /> � Facility Name CAlwu �k, 11 Phone# 1,7 1& <br /> I <br /> L Address 6 20 e, <br /> TCross Street <br /> Y Owner/Operator LO in/ �- W L�� Phone# Zor) _ y G 653 <br /> c Contractor Name Phone# <br /> O <br /> T Contractor Address 2 j 3 S pt W fl 2 �ce a� CA Lic# Class <br /> R <br /> A Insurer Work Comp# <br /> T ICC Technician's Name MWIAI-� „4ery'i1(1'X-D Expiration Date <br /> R ICC Installer's Name Ackoj, eeiv pry 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 /> I <br /> T <br /> A <br /> N <br /> K <br /> I <br /> I <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A �•1 /p <br /> N Plan Reviewers Name �v6'�«^6� Date "rD <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR VkICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS O R NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF T W RICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA" <br /> Applicant's Signature Title �t" � 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 10 �' Ar 1 +, GLC TITLE &A!4 PHONE# &-% , 0/2 f 8 <br /> ADDRESS &),o 094 g cKk C-0— 951-06' <br /> SIGNATURE DATE <br /> 2 of 6 <br />