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SAN-JOAQUIN Environmental Health Department <br /> _C-OUNTY-w <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 /> D TANK RETROFIT D PIPING REPAIR/RETROFIT )t UDC REPAIRIRETROFIT D COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 8 $S o6 3 z�pZ 1 6 <br /> Facility Name - recf<?4iy ,S� Phone# 2b9 <br /> Address ;LODO S?/rY7�5on6 Ro/4 57658T9N <br /> I Cross Street <br /> Y Owner/Operator �L//:p�N /� j,q�Q �t�4,q,C��'jY1EN'r Phone# Zp <br /> C Contractor Name N E'ffX llvc-, Phone# gp 5 C�32 —OZ 16 <br /> 0 <br /> T Contractor Address 2 y5,5H eRoW/a.4 Vc alVo`r 8 CA Lic# 5'J Z $35 Class ,t� C--/p <br /> R Insurer ti R C.4 3 o03 Work Comp#Lf6 3� Q_O� �D <br /> A GRL t�2�►A /Nsu n/�e <br /> c ICC Technician's Name Fgwm4,e-D OLS o/v "52 5�q 9 3 Expiration Date <br /> T <br /> R ICC Installer's Name $E2M 252 9 3 Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e.87 pimping sump,91 leak detector,UDC 1/2,etc.) Installed <br /> T /.�f DOO 6A I.-- F-2 4 <br /> A <br /> N <br /> K <br /> P ❑ Approved N/Approved with conditions ❑ Disapproved <br /> L See chment With Conditions) <br /> N Plan Reviewers Name Date 02/03/2021 <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. / l 1 �( <br /> NAME_�/�'ARD /`/ C97Z TITLE P%OT�G? �A/VA6CQ PHONE# 1 S06l `7 32-'-0, CJ <br /> ADDRESS ;2-7 JHIf"o,PV1N 14 VC. aNII Z� V z-k rt le 4, CA DD <br /> SIGNATURE DATE <br /> 2 of 6 <br />