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SANJ O U I Environmental Health Department <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 ❑ PIPING REPAIR/RETROFIT 0 UDC REPAIR/RETROFIT ® COLD STARTIEVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # <br /> A res �, OQI 3 �o � <br /> O Facility Name .Ll 7Z Phone # ,21 _ <br /> � Address <br /> TCross Street <br /> Y Owner/Operator h / Phone # �— / 3 <br /> C Contractor Name ,t/p Phone # 3O`�` lo4 <br /> N Contractor Address /VO4; �, YP - CA Lic # 49 Class <br /> R <br /> A Insurer „ Work Camp <br /> TICC Technicians Name <br /> T ' rrj ' ,q Expiration Date �- 3 <br /> ' <br /> ICC Installers Name <br /> R Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Current) Date UST <br /> (i.e. 67 pi-pinna sump, 91 lock detedor, UDC 1 /2, etc.) y Installed <br /> T ( � v b� �G 1J s� (Q �/ r ot/ <br /> A <br /> N <br /> K <br /> P ❑ Approved I Approved with conditions ❑ Disapproved <br /> L <br /> A Attachment With Conditions) <br /> N Plan Reviewers Name.t � � <br /> Date <br /> APPLICANT MUST PERFORM ALL WORN AC RDA THS JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HE DEPARTMENT. OWNER OR LICENSED AGENT'S 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." <br /> LA <br /> licant's Signature Tule 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 <br /> /for the billing by signature and date below. <br /> NAME (i4`},? R yf-^ZTITLE V <br /> hJA !/� PHONE #. gO1 #;7. y <br /> ADDRESS/e/t // <br /> SIGNATURE c DATE_ZeZz/ <br /> 2ofb <br />