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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERNT EXPIRES 160 DAYS FROM THE APPROVAL DATE INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT O UDC REPAJR/RETROFIT ci COLD START/EVR UPGRADE <br /> F EPA Site # — — ---( Project Contact & Telephone # CLV41 WIttikikkkH 4 0" iii <br /> AFsdllty Name Al S 'I L6 . Phone # Q 4 9 — si a 9 Tr #7 <br /> C — <br /> Address110 (p N , <br /> I crone street -4aUA1Luv1.1r t �• <br /> - - <br /> Y Owner/Opsmtor r _t 1 T� ' LAS K Phone # 01 bq ^ 4'y job <br /> o Contractor Name I � 4 Phone # <br /> SEES <br /> N ContractorAddress ( Q� 'plLtu CA Llc # l ' t I Class t s jA ,6Or H <br /> R Insurer Work Comp # <br /> T ICC Tet�nlclan's Name ' ' p �' – Explrea0n Date <br /> DICC Installer's Name Expiration Date <br /> R _ _ — <br /> Tank system work ansa Tank Size Chemicals Stored Currently Date UST <br /> (Lot ar p(ft wnp, 31 Wk doWtAw, UDC I/& sx) Installed <br /> A - - <br /> N - - - — <br /> K , , WOO <br /> P ❑ Approved ❑ Approved with conditions ❑ Disapproved <br /> L e attachment With Conditions) <br /> A <br /> N Plan Reviewers Name ` Date <br /> t- PPL=NT MUST PERFORM ALL WORK IN A41 <br /> QR E WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH WARTMENT. OWNER OR L10EN SM AGENTS SIGNATURE CERTIFIES THE FOLLOWING, 41 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I $HALL NOT EMPLOYANY PERSCN IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> wORKERB COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; I CERTIFY <br /> THAT IN THE PERFORM CE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I $HALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA' <br /> v4441 hc <br /> ., .', L , De6e <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time emended beyond permit payment coverage per <br /> tank. If the party dealgru"d below Is different then the permitapplkmM Beau property owner, the party must <br /> acknowledge this responsibility for the billing by signature and date below. <br /> �%y +� p <br /> NAME aR�-lU !;� TfRE � r �Q PHONE �k 0. 0¢ <br /> ADDRESS �f' U Ute :1 SiLLL -1 ©fit � <br /> SIGNATURE — ILL , DATE <br /> 2of8 <br /> I <br /> I <br />