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II I I i 1N]NiHVd]0 <br /> S A NCJ DA Q U I N Environmenta e7a�t��ea��Yli nVNO'IAN3 <br /> ---COUNTY <br /> BIOZ $ 7 AQN <br /> APPLICATION FOR UNDERGROUND STORAGE TAW1 —1 <br /> RETROFIT ORP PING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> TAMC RETROFIT 11 PIPING REPAIR/RETROFIT UDC REPAIR/RETROFIT ❑COLD START/EVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# Rd,,l I ie, � <br /> C Facility Name Air p Rhone# Z o S r 4_ p J <br /> 1 Address �3 q o 641p,,1, r2a 9,ti , CA q <br /> I Cross Street <br /> T <br /> Y Owner/Operator Phone# <br /> C <br /> Contractor Name 1 a 0,..01al �� j<e,,,,,,� ��,�„ '��_ Phone# 4'zS Y-+v-08 6-7 <br /> T Contractor Address 71.1,; ,•,,� Cf- "+0A 0 gyp oet CA Lic# Do SYY y Class <br /> R <br /> Insurer Cp w 2t�1 s ,'� —21,, . �,-ta Work Comp# <br /> T Date ICC Technician's Name Expiration T Cu c�a r� ez p� y �- �, <br /> R ICC Installers Name �' �dQ( SCc�.1�lctZ Expiration Date j Z-2i'-Zola' <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.97 piping sump,91 leakdolWor,UDC VZ etc.) Installed <br /> Tut)C. 1 (41 z <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L (see A achment With Conditions) <br /> Nqr �� <br /> 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: "1 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." / �-/I <br /> Applicant's Sign i Title b Data `a <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 1= <br />