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SA N sJO A Q U I N Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIRIRETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # ��� 3 SSS Z Project Contact & Telephone # kv S ham Slp y68 - L] 1 <br /> � Facility NameK ri o C `N% , abs Sfiat Ar. Phone # 2oq) g <br /> i Address 1100 S . M & t <br /> L <br /> T Cross Street 03 A & , '> •' Pw k r <br /> Y Owner/Operator j< o1deep 416j-m t jPhone # SI o)c4 f _ 23 '+ 1 <br /> C <br /> Contractor Name 'DQ ytnvu% J 1e4vv le ✓w �pl-t�/ Gdt � Phone # d Lr 4/') D -ct 03 <br /> N Contractor Address 36 Iq k �+� CA Lic # Class <br /> T <br /> A Insurer ,5Rfg4 � y. , 44 `� S.rrrs.tC rn,. d Work Comp # S tf K � SB - 1 <br /> T ICC Technician's Name C v� 1 c A, i L, .,� Expiration Date c�_ s _ Z t <br /> RICC installer's Name e EA.-e li *'0%.. Expiration Date - r _ Zo 2 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> ¢.e. 87 piping aump, 91 leak detector, UDC 112, etc.) Installed <br /> T <br /> K _ 3 10 It <br /> U bc1 7L S �+ Ve, ml-9 <br /> P ❑ Approved ®Approved with conditions El Disapproved <br /> L Cj (S Attachment With Conditions) J r { <br /> N Plan Reviewers Name Date 1 <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: "1 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 /> Applicanrs Signature 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 � � int' Jrl IMA TITLE VN QOWN1 MA04PHONE # b 2 ?J I <br /> ADDRESS ( � O O S N1 AVQ SI LU T J S VwSt EN AW k.t.Yl' ,, lnaZ - M&W 1E.CA eA L 533 7- <br /> SIGNATURE aO DATE L <br /> 2of6 <br />