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, A.'Rfl4 , <br /> Il . <br /> Lb <br /> E2r . _ .. <br /> SAN ! O A Q U I N Environmental Health DIe� rt�n9J020 <br /> COUNTY <br /> FNVIRONML= N TAL HLALTH <br /> rr,/Y 'TMENT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK - - <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 18D DAYS FROM THE APPROVAL DATE, INDICATE PERMIT TYPE BELOW: <br /> 6i( TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # Lr L <br /> A Ci/12X tS <br /> Facility Name Phone # <br /> � Ftacap G�/�5 t,,tSs 209 - 234 - m7Sli cl <br /> I Address <br /> I_ 54016 eo o STae -Cn C'i4 sea <br /> TCross Street <br /> Y Owner/Operator —S Phone # <br /> o Contractor Name R � L� Mpl rVCb� C Phone # <br /> T Contractor Address 3:Z2A- � �CptDNAL C $A CA LX Class 5 C 10 <br /> MZ <br /> A Insurer c3wrAT15 COMP FU Work Comp # j <br /> T ICC Technician's Name Expiration Date <br /> R ICC Installer's Name EUSEF310 ( 5AM 9a115A Expiration Date201 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> A <br /> N <br /> K <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L (See Attachment With Conditions) <br /> A <br /> N Plan Reviewers Name 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 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 /> 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." <br /> Applicant's Signature aad &d069Tiue e0t) pOL4 V&e .A g r Af A/P Date oZ t 23 • aP1 D;2 0 <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 t; ftWS <br /> S TITLECOWUAN A5SK1AW PHONE #_ <br /> ADDRESS 3224 gATdel ()1vA�L 10j W SAt47A fROAA 64 CTS403 <br /> SIGNATURE a% DATE �2 ' 3 0920010 <br /> 2of6 <br />