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S h N JOAQUIN <br /> 0nQUIN 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 /> 0 TANK RETROFIT 0 PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT 0 COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # I/ 0Jet "(t(i ® `• r) <br /> A Facility Name Phone # zf 7 <br /> Address V�C we, _ ), I" <br /> I Cross Street <br /> Y Owner/Operator v •V. � , to Phone # c� 6 <br /> tA <br /> Contractor Name - Xie 9 <br /> C scoot � ' ,� _ T Phone # 1 Of ' - t <br /> NCA Address l�_c�` t) �, v L S CA Lic # {�' j � � Class 's . � t b <br /> T <br /> R Insurer Work Comp # <br /> A <br /> T ICC Technician 's Name' Expiration Date <br /> QICC Installer' s Name Expiration Date <br /> R <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leek detector, UDC 1 /2, etc.) Installed <br /> T <br /> A <br /> K ��. <br /> P ❑ Approve Approved with conditions El Disapproved <br /> L (STthment With Conditions )A f Date t <br /> N Plan Reviewers Name <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:' { � <br /> Applicant's Signature " ` Title 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. f j fs <br /> NAME H AIK `t c C L TITLE Coq! t? L 1 &' ( i PHONE # <br /> ADDRESS t@ L ( l ( l %� / [tc <br /> SIGNATURE IM atia, <br /> 2 of 6 <br />