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N! <br /> l n U ,N Environmentai Hea-stip Department <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE PROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> F]TANK RETROFIT ❑PIPING REPAIRIRETROFIT DC REPAIWRETROFIT d C�/ <br /> �EPA OLD STARTIEVR UPGRADE <br /> FSite# �A� ��!�4 f✓ (��� Project Contact 8 Telephone#(A <br /> � �t !-?�- <br /> A Facility Name Phone#X2ve�–$ Z 0(Address �( ( D <br /> S Cross StreetX Lou [ � _ <br /> T 7-- Phone# <br /> Y OwnerlOperator - <br /> G <br /> Contractor Name / Phone# <br /> o '255 -53f2 <br /> lass <br /> N Contractor Address u CA LIG# <br /> T <br /> RInsurer }Q� Work Comp# <br /> A <br /> C ICC Technician's Name r j Expiration Date <br /> 7 <br /> 0i Installer's Name Expiration Date L). <br /> R <br /> Date UST <br /> Tank system work area Tank Size Chemicals Stored Currently Installed <br /> {i.e.87 piping 5-mp,87 leak deledor.UDC 112.Or-) <br /> T <br /> A M� <br /> N <br /> K <br /> P l] Approved pproved with conditions E 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 bAN <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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> 7� Title �..I CiK( Date <br /> Applicant's Signature _ <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 /> I }<5 t{nA' CZPHONE# <br /> NAMEX ��++ TITLE I 1�I <br /> ADDRESS y P <br /> SIGNATURE�` <br /> 2 stf E <br />