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SAN JOAQUIN Environmental He� W &Waiw <br /> C 0 U N 'T Y DEC 2 0 2021 <br /> APPLICATION FOR UNDERGROUND STORAGE TANKIzo ,N ,iNIENtFAL HEALTH <br /> RETROFIT OR PIPING REPAIR PERMIT ► � h: I>,� larn ► � NT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BELOW: <br /> j (TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/ RETROFIT ❑ COLD START/ EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # W -e 1 *4 iww I{ � 3( L <br /> APhone # p <br /> O Facility Name � res �t L.>`SS 6 o <br /> I Address <br /> i <br /> I Cross Street <br /> TPhone # <br /> Y Owner/Operator J" Us 3kj a - � S� ' � � � ' <br /> o Contractor Name Le WLLtqi,Lauae , L ; Phone # <br /> N Contractor Address 3 s � CA Lic # � ( Class '� �� (� <br /> T <br /> A Insurer ��� Cbl L. z ��u� Work Comp # b 'l 3a ( _ � ( <br /> T <br /> T ICC Technician ' s Name Expiration Date <br /> Q <br /> R ICC Installer' s Name 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 /> T <br /> A <br /> N <br /> K ' <br /> P ❑ Approved Approved with conditions ❑ Disapproved <br /> L S e Attachment With Conditions ) <br /> A Ar <br /> N Plan Reviewers Name /�w Date Z-2 _ <br /> t7'etfO <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 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 , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." nI ' <br /> Applicant's Signature C ,f.. 'L^ Itle � � 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/ CI}.� � � (� 1 � (� <br /> NAME AaV4 /L `//l' , I,CIdG�LCt �y TITLE Orlu n 1r,� (fL&V ' PHONE # <br /> ADDRESS D U � �1 L vl Vl A oU e ; vd-L _ 4� d2w <br /> ' <br /> SIGNATURE DATE <br /> � 1 �"1.�.�-�' <br /> 2 of 6 <br />